Medico-Legal Manual: Guidelines for Preparation of Postmortem Report

Medico-Legal Manual: Guidelines for Preparation of Postmortem Report

Introduction

• A postmortem examination (autopsy) is a systematic medical examination of a dead body conducted to determine the cause of death, manner of death (natural, accidental, suicidal, or homicidal), and the time since death.
• In medico-legal cases, postmortem reports (PMRs) are crucial legal documents prepared by qualified medical practitioners.
• They serve as primary evidence in courts of law for determining liability, crime investigation, insurance claims, and public health records.
• The Medico-Legal Manual provides guidelines and standardized formats to ensure accuracy, objectivity, and completeness of postmortem reports.
• Proper preparation of PMR prevents medico-legal disputes, protects doctors from litigation, and ensures justice in forensic and criminal cases.

Objectives of Postmortem Report

1. Establishing the cause of death.
2. Determining the manner of death (natural, accidental, suicidal, homicidal, undetermined).
3. Estimating time since death.
4. Documenting injuries, diseases, or poisoning.
5. Preserving evidence for the legal system and law enforcement.
6. Assisting in epidemiological and public health purposes.

General Guidelines for Preparation of Postmortem Report

1. Legal and Ethical Considerations

• Postmortem should only be conducted by a qualified government-authorized medical officer.
• Consent is not required in medico-legal cases but is required in clinical/academic autopsies.
• The medical officer must ensure chain of custody of evidence.
• The report must be truthful, unbiased, and objective.

2. Pre-Examination Protocol

• Receive written inquest papers (police inquest, magistrate’s order, FIR details).
• Verify identity of the deceased (name, age, gender, address).
• Note date, time, and place of postmortem examination.
• Confirm seal on body bags, clothes, or samples.
• Maintain proper registration and numbering of the PMR.

3. Structure of Postmortem Report

The report is generally divided into three major parts:

A. Introductory / Preliminary Part

• Date, time, and place of examination.
• Name, age, sex, and identification marks of deceased.
• Reference of inquest papers (police station, case number, investigating officer).
• Condition of body received (clothed/unclothed, decomposed, mutilated, charred).
• Presence of seal/tag and details of police escort.

B. External Examination

1. General Appearance:
• Height, weight, build, nourishment, complexion, rigor mortis, postmortem lividity, decomposition changes.
2. Identification Marks:
• Birthmarks, scars, tattoos, deformities, surgical scars.
3. Clothing and Articles:
• Type, condition, presence of stains, burns, tears.
4. External Injuries:
• Type (abrasion, contusion, laceration, stab, firearm).
• Location, size, shape, direction, margins.
• Relation to vital structures.
5. Natural Openings:
• Mouth, nose, ears, eyes, genitalia (bleeding, discharge, froth).

Internal Examination

Performed systematically in three cavities:

1. Cranial Cavity:
• Scalp, skull bones, meninges, brain (congestion, hemorrhage, edema, trauma).
2. Thoracic Cavity:
• Pleura, lungs (congestion, edema, consolidation, emphysema).
• Heart (size, chambers, valves, coronaries, clots).
• Great vessels, pericardium.
3. Abdominal Cavity:
• Liver, spleen, kidneys, pancreas (size, consistency, pathology).
• Stomach and intestines (contents, smell, color, mucosa).
• Urinary bladder, genital organs.
4. Spinal Examination:
• When required (trauma, suspected spinal cord injury).

Special Examination

• Collection of samples for toxicology:
• Blood, urine, stomach contents, bile, vitreous humor, hair, nails.
• Preservation of viscera in proper containers with preservatives.
• Documentation of foreign bodies (bullets, pellets, sharp weapons).
• Noting old diseases (e.g., tuberculosis, cirrhosis, myocardial infarction).

Opinion Section of Report

• Cause of death: should be specific, e.g., "Cardiorespiratory failure due to head injury."
• Manner of death: homicide, suicide, accident, natural, or undetermined.
• Time since death: approximate estimation based on rigor mortis, lividity, gastric contents, decomposition.
• If opinion cannot be given immediately → mention “Reserved pending chemical analysis/histopathology report.”

Format and Documentation

• Reports must be handwritten or typed, signed with full name, designation, and seal.
• Language must be clear, precise, and technical, avoiding ambiguous terms like probably or seems.
• Strike corrections properly, do not use overwriting.
• Maintain duplicate copies – one for record, one for police/court.

Do’s and Don’ts

Do’s

• Be objective and impartial.
• Record findings in chronological, systematic manner.
• Take photographs/sketches of injuries.
• Preserve all collected evidence carefully.

Don’ts

• Do not give personal opinions or assumptions.
• Do not mention medico-legal interpretation (e.g., who caused the injury).
• Do not delay submission of report unnecessarily.
• Avoid overwriting or illegible handwriting.

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