Reporting Necropsy Results

The ultimate purpose for performing a forensic necropsy is for the submission of a written necropsy report by the medical examiner or veterinary examiner for use in court (Adams, 2008). Therefore, the pathologist should consider the written report to be the pinnacle of the veterinary medical death investigation, with all laboratory efforts culminating in the production of a single summary document. The format of this document is at the discretion of the examiner; however, several key components will be described here. Some pathologists or other veterinarians may be required to issue a report generated using a specific software such as a laboratory information management system. Many such systems, however, are designed for the production of clinical or diagnostic reports and do not lend themselves to the production of a cleanly formatted summary report for use in court. In this case, the pathologist is encouraged, if permitted by the employer, to write a stand-alone forensic necropsy report which may either be attached to the software-generated report or submitted separately. Regardless, the veterinary examiner should clarify with the submitter at the time of submission which parties are to receive reports at the conclusion of the examination. It is advised that all correspondence be conducted only through the investigating officer and that no communication with the owner occurs.

The necropsy report should contain a concise summary of the evidence known to the veterinary examiner at the time the report was written, a thorough objective summary of the necropsy findings, and an interpretive statement that should aid the court in understanding the necropsy findings in the context of the evidence available (Davis & McDonough, 2018). Specifically, the following outline is recommended for the necropsy report, although its content and format are at the discretion of the examiner.

• 1. General information: Objective information to identify the subject of the examination should be placed in either a header or footer or at the beginning of the report. This should include at a minimum the investigating agency and/or officer; the law enforcement agency case number and/or animal identification number or name if known; the species, breed, and sex of the animal; the date of the report; the date of the necropsy; the name, title, and affiliation of the veterinary examiner; and the case number assigned by the veterinary examiner if applicable.
• 2. History: The report should contain a concise but complete summary of the historical information including witness accounts, scene findings, and veterinary medical records that have been made available to the investigating officer at the time of the necropsy. This is an appropriate section in which to describe the way the body was delivered to the examiner, including the date, time, and method of delivery. It is also appropriate to state the questions that were asked of the examiner by law enforcement to be answered by the necropsy. If the submitter declined radiography of the body prior to examination or placed any other restrictions on the examination, that should be stated here.
• 3. Necropsy results: This section should include the objective findings of the gross examination and the microscopic examination. Brief interpretive phrases are appropriate, but this section should primarily consist of unfiltered objective findings and measurements observed or recorded during the examination. This should begin with a description of the container or packaging in which the body was submitted and the presence or absence of any cooling devices such as ice packs. The preservation status (frozen, thawed, refrigerated, unrefrigerated, etc.) and postmortem condition of the body should be described (Brooks, 2016). The identifying features of the body including weight, measurements, hair coat color and length, and sex should be described. The features of the external and internal examination should be described. Results of the microscopic examination should

be included, stating all tissues that were examined. The results of any ancillary test procedures should be included if applicable, along with the name of the laboratory at which those analyses were conducted. The examiner may choose to summarize the gross and microscopic findings for clarity under a heading such as Pathologic Anatomic Findings.

4. Cause and manner of death: The examiner’s professional opinion regarding the cause of death, and the subsequent opinion section that expands upon this cause, are arguably the most important items contained within the necropsy report. Up to this point, the report contains entirely objective information provided either by the investigating officer or by the examiner through the course of the gross and microscopic examination. Only at this point in the report does the language change to that of opinion. The examiner is typically expected to provide the court with the cause of death of the victim examined. Cause of death is defined as the initiating event that resulted in the death of the victim. This may be further subdivided into immediate, also known as proximate, cause of death and underlying cause of death. The immediate or proximate cause of death is the final disease, injury, or condition that resulted in death. The underlying cause of death is the initial disease, injury, or condition that began the chain of events that ultimately led to death. Another term that is sometimes used, contributory cause of death, is a condition found in the victim that affected the progression of physiologic changes resulting in death but did not cause that sequence of events to begin. Some pathologists also prefer to include a mechanism of death, which is defined as the physiological process that resulted from the previously stated cause of death. For complex situations, the mechanism of death may add clarity to the sequence of events described in the report; otherwise, it often is unnecessary and does not need to be considered essential.

The manner of death is defined as the legal classification of a death as having resulted from a natural cause, an accidental injury, or an intentional injury (Figure 10.12). Assigning a manner of death to a victim is a complex process that must include consideration of both the necropsy findings and the investigative findings, such as the known or reported event history and scene findings. The manner of death assignment in human death investigations typically is one of five classifications: natural, accidental, suicide, homicide,

Manner of death in human and animal death investigations

Human

Natural

Accidental

Suicide

Homicide

Undetermined

Animal

Natural

Accidental*

Nonaccidental*

Includes both nonaccidental injuries and neglect Undetermined

(‘Accidental and nonaccidental manners of death may by collectively considered as unnatural.)

Figure 10.12 Classifications for the manner of death used in human death certificates and proposed classifications for the manner of death for use in animal death investigations.

or undetermined. Because suicide is not applicable to animal victims, this classification is removed for veterinary forensic investigations. Because the term homicide is not directly applicable to a nonhuman victim, this term is replaced by nonaccidental injury. Thus, the four classifications for manner of death in veterinary medicine are: natural, accidental injury, nonaccidental injury, or undetermined (Figure 10.12). The distinction between accidental and nonaccidental injury may be difficult and often relies heavily on the consideration of the synthesis of all of the case findings. Alternatively, accidental and nonaccidental manners of death may by collectively considered as unnatural. If the examiner is not able to determine the manner of death to a reasonable degree of certainty, then this classification should be listed as undetermined. Ideally the examiner will discuss the case with the investigator and/or the prosecutor in order to determine whether or not it is preferred to include manner of death in the report.

5. Opinion: The opinion section is simply the verbalization of the summary of the necropsy findings and the overall interpretation of the cause and manner of death. Beyond the cause and manner of death, this is the most valuable portion of the necropsy report for the court. It is critical that the opinion is written in plain language that is understandable to the court, including all members of the jury, and that all statements and interpretations made by the examiner are carefully presented to avoid bias or speculation. In the opinion statement, the examiner is expected to verbally address the questions asked by the submitter at the time of submission.

It is generally expected that the necropsy report will be submitted to the investigating law enforcement agency in a timely manner and by the route requested at the time of submission. Turnaround times are affected by caseload and complexity and by the extent of ancillary testing; however, this should be discussed with the submitter at the time of submission so that the investigator has realistic expectations. The parties should also discuss practices for future communications on this case and the expectations of the examiner in the subsequent legal proceedings.

As stated previously, at the completion of the necropsy all that remain of the permanent record are often the photographs and radiographs as well as the necropsy report. It is absolutely essential that these items are retained securely and filed in a manner that allows for their ready retrieval if records are requested by law enforcement or subpoena by an agent of the court.

References

Adams, V. I. 2008. Guidelines for Reports by Autopsy Pathologists. Totowa, NJ: Humana Press.

Anderson, G. 2013. Forensic entomology: The use of insects in animal cruelty cases. In Veterinary Forensics: Animal Cruelty Investigations, edited by M. Merck, 273-286. Ames, I A: John Wiley & Sons, Inc.

Brooks, J. and Sutton L. 2018. Postmortem changes and estimating the postmortem interval. In Veterinary Forensic Pathology, edited by J. W. Brooks, 43-63. Cham, Switzerland: Springer.

Brooks, J. W. 2016. Postmortem changes in animal carcasses and estimation of the postmortem interval. Veterinary Pathology. 53(5):929-40.

Brooks, J. W. 2018a. Veterinary Forensic Pathology, 1st ed. Vol. 1, edited by J. W. Brooks. Cham, Switzerland: Springer.

Brooks, J. W. 2018b. Veterinary Forensic Pathology, 1st ed. Vol. 2, edited by J. W. Brooks. Cham, Switzerland: Springer.

Brownlie, H. W. and Munro, R. 2016. The veterinary forensic necropsy: A review of procedures and protocols. Veterinary Pathology. 53(5):919-928.

CDC, Centers for Disease Control and Prevention. 2015. Public Health Law Program: Coroner/Medical Examiner Laws by State. Available from www.cdc.gov/publications/coroner.

Davis, G. and McDonough, S. P. 2018. Writing the necropsy report. In Veterinary Forensic Pathology, edited by J. W. Brooks, 139-149. Cham, Switzerland: Springer.

Dettmeyer, R.B. 2011. Forensic Histopathology: Fundamentals and Perspectives. New York: Springer. Gerdin, J. A. and McDonough, S. P. 2013. Forensic pathology of companion animal abuse and neglect.

Veterinary Pathology. 50(6):994-1006.

Institute of Medicine (U.S.). Committee for the Workshop on the Medicolegal Death Investigation System. 2003. Medicolegal Death Investigation System: Workshop Summary. Washington, DC: National Academies Press.

Kagan, R. and Brooks, J. 2018. Performing the forensic necropsy. In Veterinary Forensic Pathology, edited by J. W. Brooks, 27-42. Cham, Switzerland: Springer.

Lew, E. O. and Matshes, E. W. 2005. Death scene investigation. In Forensic Pathology: Principles and Practice, edited by D. Dolinak, E. W. Matshes and E. O. Lew, 9-64. New York: Elsevier/Academic Press.

Maloney, M. S. and Housman, D. 2014. Crime Scene Investigation Procedural Guide, edited by R. M. Gardner. Boca Raton: CRC Press.

McDonough, S. P., Gerdin, J., Wuenschmann, A., McEwen, B. J. and Brooks, J. W. 2015. Illuminating dark cases: Veterinary forensic pathology emerges. Veterinary Pathology. 52( 1):5-6.

McDonough, S. P. and Southard, T.L. 2017. The Necropsy Guide for Dogs, Cats, and Small Mammals. Ames: IA: Wiley-Blackwell.

Merck, M., Miller, D. and Maiorka, P. C. 2013. CSI: Examination of the animal. In Veterinary Forensics: Animal Cruelty Investigations, edited by M. Merck, 37-68. Ames, IA: Wiley-Blackwell.

Meyerholtz, K. A., Wilson, C. R., Everson, R. J. and Hooser, S. B. 2011. Quantitative assessment of the percent fat in domestic animal bone marrow. Journal of Forensic Sciences. 56(3):775-777.

Munro, R. and Munro, H. 2011. Forensic veterinary medicine 2. Postmortem investigation. In Practice. 33(6):262-270.

Murphy, L. A. and Kagan, R. 2018. Poisoning. In Veterinary Forensic Pathology, edited by J. W. Brooks, 75-87. Cham, Switzerland: Springer.

Ottinger, T., Rasmusson, B., Segerstad, C. H., Merck, M., Goot, F. V, Olsen, L. and Gavier-Widen, D. 2014. Forensic veterinary pathology, today’s situation and perspectives. Veterinary Record. 175(18):459.

Peterson, G. F. and Clark, S. C. 2006. Forensic autopsy—Performance standards. American Journal of Forensic Medicine and Pathology. 27(3):200-225.

Rogers, E. R. and Stern, A. W. 2018. Veterinary Forensics: Investigation, Evidence Collection, and Expert Testimony. New York: CRC Press.

Touroo, R., Brooks, J., Lockwood, R. and Reisman, R. 2018. Medicolegal investigation. In Veterinary Forensic Pathology, edited by J. W. Brooks, 1-8. Cham, Switzerland: Springer.

Touroo, R. and Fitch, A. 2018. Crime scene findings and the indentification, collection, and preservation of evidence. In Veterinary Forensic Pathology, edited by J. W. Brooks, 9-25. Cham, Switzerland: Springer.