Forensic Pathology

Goals and Objectives

Level: PGY-1, PGY-2, PGY-3, PGY-4 and PGY-5

In the CBD cohort, junior residents are considered to be PGY-1 and PGY-2 while senior residents are considered to be PGY-3 and PGY-4.  PGY-5 CBD residents are also considered to be senior residents within the CBD curriculum. The ultimate goal is to allow for independence in the form of performing the postmortem examination of a routine coroner case and supervision of junior residents.

During forensic pathology rotations, there is no separation of cases based on complexity or training year.  Due to the nature of forensic pathology (all cases are ultimately supervised, reviewed and finalized by a supervising staff), a resident in any training level may observe or participate (depending on skill level) in a forensic postmortem examination.

It is expected that the first forensic pathology rotation by a junior resident will result in the mastery of normal anatomical landmarks used during postmortem examination, acquisition of the skills in the basic postmortem technique (as outlined below), and knowledge of the components of a preliminary forensic autopsy report.

The basic postmortem examination techniques consist of (EPAs: TTD#2, F#4, C#6, C#7):

  • Checking the decedent’s identity with the supervisor at the start of the postmortem examination
  • Performance of a detailed external examination (inclusive of identification and documentation of all injury types)
  • Evisceration of a body (inclusive of opening the rib cage)
  • Removal of a brain from the opened cranial cavity
  • Detailed systematic examination and documentation of all internal findings (natural disease and injuries/effects of injuries)
  • Procurement of the appropriate samples for ancillary testing as indicated (bacteriology, virology, etc)
  • Dissection of all major organs
  • Selection of tissue samples for histological examination
  • Procurement of samples for DNA analysis as indicated.

Based on experience and acquisition of skills, the tasks will be become progressive with a goal of the resident being able to complete a routine forensic postmortem examination, including evisceration, under the supervision of the staff forensic pathologist or forensic pathology fellow.

Subsequent forensic pathology rotations will build on the above foundation and include the ability to independently procure samples for ancillary testing and produce a draft preliminary and final forensic pathology report which should be free of typographical errors.

Experienced residents who have demonstrated mastery of basic postmortem technique will then learn special postmortem examination techniques.  Special postmortem techniques refer to:

  • Musculocutaneous dissection of the torso and limbs as indicated
  • Layered dissection of the anterior neck structures in a bloodless field (dry neck dissection)
  • Facial dissection
  • Removal of the spinal cord (anterior or posterior approach)
  • Removal of a long bone.

The PGY-5 year is one of senior leadership and the resident should be able to assume responsibility for organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard texts and be prompt in using the literature to solve specific problems.

Due to the persistent trend of decreasing hospital autopsy cases across Canada, forensic autopsies of routine medical deaths may be used to complete hospital autopsy EPAs (EPAs: TTD#2, F#4, C#6).

In the event that there are no forensic autopsy cases, the resident may be required to review other forensic case materials including histologic slides, toxicology reports, etc and prepare draft forensic pathology reports.  

During the course of residency, the AP resident is expected to:

  • Perform approximately 50 routine postmortem examinations (consented hospital and coroner’s cases) on adult decedent’s (EPAs: TTD#2, F#4, C#6, C#7, TTP#1).
  • When permitted by the supervisor, take ownership of any postmortem examination performed in terms of the timely preparation of a draft report (with conclusions) and timely submission of the case file to the Administrative Assistant for processing (EPAs: C#6, C#7, TTP#1).
  • Review the histological findings of the case with the supervisor (EPAs: C#6, C#7).
  • Review and interpret the results of biochemical analysis of the vitreous fluid (EPA: C#7).
  • Review and interpret the results of determination of the glycated hemoglobin concentration (EPA: C#7).
  • Review and interpret the results of the toxicological analysis on bodily fluids (EPA: C#7).
  • Maintain a log book of all medicolegal postmortem examinations which were performed under supervision or had been observed. For each case, the recorded information will consist of case number, age, sex, date performed, cause of death, known manner of death and supervisor.
  • Provide a summary of the cases performed under supervision and observed.
  • Maintain a log book of all basic and special postmortem examination techniques either performed or had been observed according to case number, nature of basic technique, nature of the special technique and supervisor.

PGY1 and PGY2 Rotations

  • Introduce residents to the basic approach and performance of a medicolegal postmortem examination (EPAs: F#4, C#6, C#7).
  • Reinforce the basic knowledge and skills of the postmortem examination learnt in the previous blocks of hospital postmortem examination (EPAs: F#4, C#6, C#7).
  • Development of the requisite skill sets needed to approach and perform forensic postmortem examinations in non-criminally suspicious, natural and unnatural deaths (suicides and accidents) (EPA: C#7).
  • Developed the requisite skills necessary to recognize criminally suspicious deaths by direct observation of staff forensic pathologists who conduct these examinations.
  • Provide opportunities to foster and develop interests in forensic pathology.
  • Provide support and career guidance for those AP residents who are interested in a career in forensic pathology (EPA: TTD#4).

PGY2-5 Rotations

The PGY3/4 rotations will build further on the knowledge and skill sets of the medicolegal postmortem examination acquired in the PGY2 rotation with greater emphasis placed on the types of cases that involve asphyxia, gunshot wounds, blunt force injury, sharp force injury and non-suspicious deaths of children under the age of 5.

The CanMEDs objectives will be as follows:

Medical Expert (EPAs: TTP#1, F#4, C#6, C#7)

General Requirements

  • Be able to identify an awareness of any limitations of knowledge and skill sets which will preclude the undertaking of any particular postmortem examination (EPAs: F#4, C#6, C#7).
  • Demonstrate an awareness of biosafety considerations and risk minimization prior to the performance of postmortem examinations in infectious cases eg tuberculosis, HCV, HIV (EPAs: F#4, C#6, C#7).
  • Identify those cases in which radiological imaging of the body (eg skeletal survey) is applicable prior to the postmortem examination eg gunshot wound cases, severely burnt bodies, sudden unexpected death in infancy (EPAs: F#4, C#6, C#7).
  • Appreciate an understanding of and need for the collection of various trace evidence exhibits in the criminally suspicious deaths at the start of the postmortem examination (EPAs: F#4, C#6, C#7).
  • Demonstrate the ability to gather and enquire into all relevant information (medical and circumstantial) before beginning a postmortem examination. Be able to interrogate the clinical and laboratory records and understand the utility and limitations associated with various types of investigation including imaging, microbiology and biochemistry (EPAs: F#4, C#6, C#7).
  • Exhibit an understanding of the use of clinical information and the health record in autopsy examination and be able to identify any clinical issues to be addressed and resolved by the autopsy examination (EPAs: F#4, C#6, C#7).
  • Demonstrate an awareness of the need to consider and review the findings of the scene of death/discovery of a body prior to starting a postmortem examination in community deaths (EPAs: F#4, C#6, C#7).
  • Demonstrate and apply knowledge of normal anatomy, physiology and biochemistry (EPAs: F#4, C#6, C#7).
  • Anticipate and discuss with the coroner the need for and appropriate retention of whole organs (eg brain, spinal cord, eyes, heart) for specialist examination in case-specific scenarios eg retention of the heart in a sudden death in a young person with a negative autopsy (EPA: C#7).
  • Seek appropriate case-specific specialist consultations eg cardiac pathology, neuropathology (EPA: C#7).
  • Describe and apply common methods of evisceration and organ dissection techniques relevant to routine autopsy practice (EPAs: F#4, C#6, C#7).
  • Be able to describe the special techniques utilized in forensic pathology eg vertebral artery exploration (EPA: C#7).
  • Understand and apply the difference between cause and manner of death (EPA: C#7).
  • Formulate Cause of Death statements according to the WHO formulations (EPA: C#7).
  • Understand the basic principles of cell biology, immunology and pathogenesis and the changes that occur in disease states.
  • Confidently and correctly identify the macroscopic features of the major disease processes encountered in routine autopsy practice (EPAs: F#4, C#6, C#7).
  • Demonstrate knowledge of the methods of identification of an unidentified decedent (EPA: F#4).
  • Apply the methods of identification of an unidentified body in a stepwise manner to establish identity of an unknown decedent (EPA: C#7).
  • Be familiar with the effects of time, heat, cold, drying and humidity on body tissues (EPA: C#7).
  • Learn the technique for removing a brain after the skull has been opened (EPAs: F#4, C#6, C#7).
  • Learn how to take vitreous fluid (EPA: C#7)
  • Introduction of the technique of eye removal via a posterior approach (EPA: C#7).
  • Learn about special needs of certain religions (EPAs: F#4, C#6, C#7).

Specific Requirements

  • Understand the Ontario medicolegal system of death investigation and compare and contrast with other medicolegal systems in Canada (EPA: C#7).
  • Read and understand the Coroner’s Act (EPA: C#7).
  • Be able to confirm identity of the body just prior to autopsy from identification of the coroner’s identification tag and record the manner of identification (EPA: C#7)
  • Appreciate the need to consider and procure the various relevant trace evidence samples from the body in criminally suspicious deaths in an uncontaminated manner at the very start of the post mortem examination (EPA: C#7).
  • Appreciate the need to establish and guarantee chains of custody of the specimens obtained (EPA: C#7).
  • Demonstrate the ability to perform and document the significant positive and negative findings on external examination of a body at postmortem using body diagrams, descriptions and photographs (EPAs: C#6, C#7).
  • Be able to appropriately classify, describe and document injuries on external examination (written descriptions, body diagrams and photographs) (EPA: C#7).
  • Ensure that satisfactory photographs of external and internal injuries/other significant findings at autopsy are taken during the postmortem examination, either by the resident, technical staff or the police personnel in attendance (EPAs: C#6, C#7).
  • Demonstrate an awareness of the various methods of organ evisceration and an appreciation of their application in case-specific circumstances (EPAs: C#6, C#7).
  • Be able to perform a thorough and systematic dissection of the organs and record the findings (descriptions, diagrams and photographs) (EPAs: C#6, C#7).
  • Be able to identify and correctly interpret the positive anatomical findings on organ dissection (EPAs: C#6, C#7).
  • Demonstrate a superior and detailed knowledge of the normal gross and light microscopic appearance of tissues.
  • Be able to recognize the microscopic appearance of normal and diseased tissues appropriate to the experience of a general anatomical pathologist.
  • Demonstrate the ability to consider, apply knowledge of and procure appropriate samples for the relevant ancillary postmortem investigations as indicated (histopathology, toxicology, biochemistry, microbiology, molecular studies, electron microscopy and other studies) (EPA: C#7).
  • Identify postmortem changes and artifacts that arise from decomposition and animal predation (EPA: C#7).
  • Demonstrate the ability to interpret postmortem findings in the context of the clinical history, circumstances of death and scene investigation and arrive at a cause of death statement in accordance with the WHO format based on clinicopathological considerations (EPAs: C#6, C#7).

Communicator (EPAs: C#7, C#14, C#18, TTP#1, TTP#5, TTP#6)

General Requirements

  • Establish effective relationships with coroners, physicians, morgue technical staff, police, next-of-kin where indicated, and forensic scientists as applicable (EPAs: C#14, C#18, TTP#5, TTP#6).
  • Be able to elicit additional information from the coroner, police and other medical practitioners (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Verbally discuss and appropriately feedback the results of the postmortem examination with the requesting coroner at the end of the postmortem examination (EPAs: C#14, C#18, TTP#5, TTP#6).
  • Observe the staff pathologist verbally discuss and appropriately feedback the results of the postmortem examination with the attending police officers at the end of the postmortem examination (EPAs: C#14, C#18, TTP#5, TTP#6).

Specific Requirements

  • Verbal appraisal of the coroner of the findings and the pathologically determined cause of death at the end of the postmortem examination (EPA: C#7).
  • Completion of the “Summary of Findings” form of the Ontario Forensic Pathology Service as appropriate (EPA: C#7).
  • Completion of the “Toxicology Submission Form” of the Centre for Forensic Sciences that accompanies the toxicology specimens as appropriate (EPA: C#7).
  • Completion of the Biochemistry analysis submission form for vitreous fluid as appropriate (EPA: C#7).
  • Completion of ALL relevant ancillary investigation request forms as appropriate (EPA: C#7).
  • Preparation of the draft and final medicolegal autopsy reports to a high standard for the coroner (EPA: C#7).
  • Understand the and demonstrate role and duties of an expert witness in the delivery of forensic pathology evidence in court (EPA: C#7).

Collaborator (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)

General Requirements

  • Consult effectively with other medical, pathology and forensic pathology professionals (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Appreciate the value of teamwork involving experts in other forensic sciences such as anthropology, odontology, police specialists and firearms/ballistics in the investigation of suspicious deaths (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific Requirements

  • Utilize sufficient experience in clinical medicine to advise on the significance of pathological findings determined on postmortem examination (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Advise concerned parties on the appropriate further investigations to be pursued based on the preliminary findings of the postmortem examination (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Manager (EPAs: C#14, C#15, C#17, C#18, TTP#1, TTP#3, TTP#4, TTP#5, TTP#6)

General Requirements

  • Utilize resources effectively for optimal cost-benefit ratios in forensic pathology practice, but without compromising quality of work (EPA: C#17, TTP#4).
  • Work effectively and efficiently in a health care organization (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Utilize information technology to optimize life-long learning and other activities (EPA: C#17, TTP#4).

Specific Requirements

  • Demonstrate knowledge of the principles of laboratory management (EPAs: C#15, TTP#3).
  • Demonstrate knowledge of the methods of quality control in the laboratory EPAs: C#15, TTP#3).
  • Demonstrate knowledge of the methods of risk management and professional quality assurance as applied to forensic pathology (EPAs: C#15, TTP#3).

 Health Advocate (EPAs: C#6, C#7, TTP#1)

General Requirements

  • Understand the need for next-of-kin genetic counseling following the finding of congenital/genetic disorders at postmortem examination (EPAs: C#6, C#7, TTP#1).
  • Understand the contribution of postmortem examination results to overall community health and safety (EPAs: C#6, C#7, TTP#1).

Specific Requirements

  • As members of an interdisciplinary team of forensic professionals, the pathologist will endeavor to ensure that standards of autopsy practice are regularly reviewed to meet community needs (EPAs: C#6, C#7, TTP#1).
  • In conjunction with the coroner, the value of the autopsy to general community health and well-being will be reinforced to the public (EPAs: C#6, C#7, TTP#1).

Scholar (EPAs: C#16, C#17, TTP#4)

General Requirements

  • Develop, implement and monitor a personal continuing medical education strategy (EPA: C#17, TTP#4).
  • Critically appraise sources of medical, scientific and other information (EPAs: C#9, C#10, C#15, C#16, TTP#4).
  • Facilitate the learning of other medicolegal death investigation professionals (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Contribute to development of new knowledge (EPAs: C#16, C#17, TTP#4).

Specific Requirements

  • Present cases/postmortem examination topics during the Monday residents’ academic day (EPA: C#14). 
  • The resident may consider undertaking a small research proposal, initiated either by himself/herself or by a supervising staff member and should be able to critically appraise the results (EPA: C#16).
  • The resident may be asked to present the results of conducted research at a local, national or international meeting of forensic professionals with the support of the supervisor (EPA: C#16).

Professional (EPAs: C#5, TTP#1, TTP#2, TTP#6)

General Requirements

  • Perform highest quality work with integrity and compassion.
  • Exhibit appropriate personal and interpersonal professional behaviors.
  • Practice ethical medicine.
  • Demonstrate respect for all genders, cultures and ethnic groups in autopsy practice.

Specific Requirements

  • Act as an appropriate role model for others (EPAs: TTP#2, TTP#6).
  • Demonstrate a professional attitude to colleagues (EPAs: TTP#2, TTP#6).
  • Have an appreciation of the crucial role of the forensic pathologist in judicial matters and in general community health and safety.  This will include knowledge of individual professional limitations and the necessity of seeking appropriate second opinions (EPAs: C#5, TTP#1 TTP#6).

Instructional Tools

The resident will meet with the Forensic Pathology Section Head and go over this document and the overall aspects of the rotation the day before the rotation starts.

Evaluation

  • Optional: the resident may choose to do a presentation at the end of their junior or senior Forensic Pathology rotation. The resident will choose a topic of interest. The presentation can be case based if the resident had an interesting or challenging case during the rotation that can serve as a starting point. The presentation should include review of the recent literature about the topic and cite specific references.
  • Mid-rotation evaluation to be completed by the forensic pathology section head with input from other forensic pathologists.
  • Final evaluation to be completed by the forensic pathology section head following evaluations completed by all forensic pathologists encountered during the rotation. The forensic pathology section head evaluation will also include results of the:
    • End of rotation examination (junior and senior residents)
    • End of rotation presentation, if applicable
  • Expectations will be graded according to the level of training

Recommended Reading

Autopsy Pathology: a Manual and Atlas, 3rd Ed. Connolly, Finkbeiner, Ursell and Davis, Philadelphia: Elsevier, 2016.

Ontario Forensic Pathology Service 2022 Practice Manual for Registered Pathologists (copy available in the Forensic Unit).

The Ontario Coroners Act (available at https://www.canlii.org/en/on/laws/stat/rso-1990-c-c37/latest/rso-1990-c-c37.html).

Forensic Pathology, 2nd Ed. DiMaio and DiMaio, Boca Raton: CRC Press, 2001.

Knight's Forensic Pathology, 4th Ed. Saukko and Knight, Boca Raton: CRC Press, 2016.

Atlas of Forensic Histopathology. Cummings, Trelka and Springer, Cambridge: Cambridge University Press, 2011.

 

Updated June, 2022

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