The evolution of postmortem investigation: a historical perspective on autopsy's decline and imaging's role in its revival

Abstract

Autopsy is generally regarded as the gold standard for cause of death determination, the most accurate contributor to mortality data. Despite this, autopsy rates have substantially declined, and death certificates are more frequently completed by clinicians. Substantial discrepancies between clinician-presumed and autopsy-determined cause of death impact quality control in hospitals, accuracy of mortality data, and, subsequently, the applicability and effectiveness of public health efforts. This problem is compounded by wavering support for the practice of autopsy by accrediting bodies and academic bodies governing pathology specialty training. In forensic settings, critical workforce shortages combined with increased workloads further threaten sustainability of the practice. Postmortem imaging (PMI) can help mitigate these ongoing problems. Postmortem computed tomography can help clarify manner and cause of death in a variety of situations and has undeniable advantages, including cost reduction, the potential to review data, expedient reporting, archived unaltered enduring evidence (available for expert opinion, further review, demonstrative aids, and education), and (when feasible) adherence to cultural and religious objections to autopsy. Integration of radiology and pathology is driving a transformative shift in medicolegal death investigations, enabling innovative approaches that enhance diagnostic accuracy, expedite results, and improve public health outcomes. This synergy addresses declining autopsy rates, the forensic pathologist shortage, and the need for efficient diagnostic tools. By combining advanced imaging techniques with traditional pathology, this collaboration elevates the quality of examinations and advances public health, vital statistics, and compassionate care, positioning radiology and pathology as pivotal partners in shaping the future of death investigations.

Keywords: autopsy; forensic medicine; pathology; postmortem computed tomography (PMCT); postmortem imaging; radiology; virtual autopsy.

Figure 1

Schematic illustrating the integration of postmortem imaging at forensic centers for the purpose of autopsy triage.

Figure 2

Case example depicting an abdominal gunshot wound (51). The axial slices with a hard kernel and bone window (a) and a soft kernel with soft tissue window (b) represent the two standard CT data visualizations. In these images, which display slices perpendicular to the scan axis, only the entry wound is visible (a and b, arrow). One advantage of virtual autopsy using CT is its ability to provide three-dimensional data, and through multi-planar reformations (c–e), the orientation of key findings—such as the bullet trajectory [(c–e), dashed markings]—can be adjusted accordingly. Three-dimensional visualizations, including volume rendering (f), cinematic rendering (g), and maximum-intensity projection (h), offer impressive depictions that enhance understanding, even for non-radiologists. For example, the gunshot wound at the skin surface is clearly visible [(f), red circle], as is a fracture of the 13th rib [(g,h), red circle]. Different visualization techniques can be selected depending on the specific findings; but whether those findings are recognized depends on the observer's training and experience.