CLINICAL, EPIDEMIOLOGICAL AND MESOLOGICAL CHARACTERISTICS OF AVOIDABLE DEATHS IN THE CASUISTRY OF FORENSIC SERVICE OF SIBIU COUNTY
ELENA TOPÎRCEAN
1, CARMEN DANIELA DOMNARIU
21PhD Candidate “Lucian Blaga” University of Sibiu, 2“Lucian Blaga” University of Sibiu
Keywords: avoidable death, forensic autopsy, cardiovascular diseases, Certificate of the Fact of Death
Abstract: Forensic casuistry is an important source of cases that fall into avoidable deaths category;
these include: deaths due to road accidents, sudden cardiac deaths, deaths due to hepatic cirrhosis, deaths in children under 1 year, maternal deaths etc. In the work carried out as a resident physician in forensics, I found a large, growing number of deaths due to diseases/accidents amenable to health care or primary prevention. The aim of this study was to identify the avoidable deaths from the forensic cases of Sibiu County and the clinical, epidemiological and mesological features thereof, with a thorough analysis of those caused by cardiovascular diseases. Specifically, it is a descriptive, analytical observational ambispective study conducted over a period of 10 years from 2006 to 2015. In the forensic casuistry of Sibiu, we identified 1178 avoidable deaths within 10 years, representing 40% of all forensic autopsies. In dynamics, their share of all forensic deaths increased up to 6% (in 2006, 37% of forensic deaths fell into the category of avoidable deaths, and in 2015, the share was of 43%). We found a much higher frequency of avoidable deaths in men and in people from urban areas, as well as the increase of the average age of victims of avoidable deaths by about five years in the ten years studied.
Cardiovascular diseases caused around half of all avoidable deaths with forensic consequences (about 49%), and another 40% of them were due to traffic accidents, the forensic prerogative. The study found that most of the victims of avoidable deaths due to cardiovascular diseases with forensic consequences had the following characteristics: Romanian nationality, Orthodox religion, married or divorced, graduates of vocational schools, no occupation. On the one hand, this study provides an accurate assessment of the need for guidelines and protocols for primary, secondary and tertiary prevention, representing a foundation for the effective identification and monitoring of risk groups with different allocation of resources to priority areas of intervention. On the other hand, the study allows predictions on the dynamics of these types of deaths and therefore, on the dynamics of human resources in Romania.
1Corresponding author: Elena Topîrcean, Str. Cristianului, Nr. 4, Cod 557170, Orlat, Judeţul Sibiu, România, E-mail: [email protected], Phone:
+40737 002054
Article received on 19.11.2016 and accepted for publication on 05.12.2016 ACTA MEDICA TRANSILVANICA December 2016;21(4):1-5
INTRODUCTION
The death of a person becomes a forensic case after the notification of the criminal investigators, if it fulfils the criteria provided by the law.(1,2) The situations in which death is a forensic case are the following: the violent death (mechanical, physical, biological or chemical), the cause of death is unknown and suspicious death.(3) Suspicious death also includes the death of a person who is in full state of apparent health, which often is the prerogative of cardiovascular disease, common causes of avoidable deaths.
Given that among the possible causes of deaths with forensic implications, there are found many of the causes of avoidable deaths in Romania (4,5), forensic casuistry is considered an important source of cases that comply with the criteria for inclusion in a study on avoidable deaths. Some examples would be: deaths due to road accidents, deaths due to cirrhotic liver, deaths in children under 1 year, maternal deaths, sudden cardiac deaths, deaths due to toxic-septic shock etc.
In the work carried out as a resident physician in forensics, I have found a large, growing number of deaths due to diseases/accidents amenable to health care or primary prevention. This was the impetus for the accomplishment of this laborious research in order to identify vulnerable population groups and the “risk factors” that amplify this phenomenon.
The forensic pathologist occupies a privileged position in terms of addressing the carers of a man who had an avoidable death, being able to obtain firsthand, useful information on the area of origin, religion, educational level, occupation, previous medical history, any medical examinations and/or hospitalization etc. of the deceased. Thus, the forensic pathologist corroborates the data obtained from carers with that indicated by the forensic necropsy. The close cooperation of the forensic pathologist with the criminal investigation bodies (research carried out on site, access to the entire case file) helps integrating information in a unified and complex vision.(6,7)
Another advantage of the forensic pathologist in identifying and elucidating these types of deaths is that he knows the autopsy final findings, established after the completion of all complementary examinations.
Typically, statistical information related to death has as a starting point the data mentioned in the Certificate of the Fact of Death, that are usually truthful.(8,9)
There are also situations when these attestations include the initial conclusions that can be disproved/corrected later, after conducting further examinations; these do not get to be recorded in the Certificate of the Fact of Death previously issued. This is why there is an underreporting of avoidable deaths.
PURPOSE
The study aims at identifying avoidable deaths from the forensic cases of Sibiu County and the clinical and epidemiological features thereof.
The main objectives of this study were: assessing the extent of avoidable deaths from the forensic cases of Sibiu County, in order to clarify the magnitude of the phenomenon and the weight of these deaths in total deaths with forensic consequences, namely to establish the dynamics of avoidable deaths of forensic nature in Sibiu County, assessing their frequency and analyzing the determining causes.
MATERIALS AND METHODS
We conducted a descriptive observational ambispective study (10) for a period of 10 years (2006-2015) on all avoidable deaths with forensic consequences, in Sibiu County.
The material under study is represented by the entire deaths casuistry of Forensic Service of Sibiu County and Forensic Office of Mediaş from January 2006 - December 2015.
We analyzed the forensic, necropsy reports, the Certificates of the Fact of Death, toxicological analysis bulletins, histopathology reports, medical documents related to the medical history of cases and, in some cases, the research records of the criminal investigation bodies.
RESULTS
Between 2006 and 2015, at the level of Sibiu County, there were performed 2931 autopsies within the Forensic Service of Sibiu County and in the Mediaş Forensic Office.
The annual average of forensic autopsies was 293.
About half of the deaths that required forensic autopsy (1178 cases - 40.19%) were classified as avoidable deaths, their annual average being 118.
Annual percentage of avoidable deaths in all deaths with forensic implications, in the first year, respectively in the last year of the study period of time was of 37.25% (in 2006) respectively 43.00% (in 2015), highlighting an increase by about 6% in 2015, compared to 2006. The maximum percentage share was of 43.58% and it was recorded in 2009 (table no. 1).
Table no. 1. Annual distribution of forensic autopsies and distribution of avoidable deaths of forensic nature in Sibiu County, between 2006 and 2015
Year No. of forensic autopsies Avoidable deaths no. percentage- %
2006 357 133 37.25
2007 302 121 40.07
2008 305 119 39.01
2009 293 113 38.57
2010 264 98 37.12
2011 257 112 43.58
2012 290 123 42.41
2013 261 103 39.46
2014 302 127 42.05
2015 300 129 43.00
Total 2931 1178 40.19
Over three quarters (78.78%) of total avoidable deaths identified in total forensic autopsies performed in Sibiu County occurred in men, the percentage of women being of 21.22%.
Although the dynamic analysis confirmed the predominance of males every year, there are significant annual differences between genders, such as: sex ratio - male:female in 2008 was 2.6:1, sex ratio in 2013 = 5.8:1. Overall, in the last period of study, namely between 2011 and 2015, gender difference increased along with the amplification of the phenomenon in men (table no. 2).
Analyzing the avoidable deaths identified in all forensic cases, from the point of view of the deceased’s age, we observed annual variations of the average age, between 45, 65 years old, value recorded in 2006, and 51 years old, value recorded in 2013. Generally, the average age in case of avoidable deaths was 48.63 years and standard deviation - 15.51. We also highlighted the increase of the average age, from 45,65 years (in 2006) to about 51 years in 2012-2015 (table no.
3). Relating the avoidable deaths identified in the forensic casuistry of Sibiu County to the area of origin of the deceased, has revealed the higher frequency of urban area, 659 of the victims of avoidable deaths with forensic consequences (56%) were in urban areas, compared with 519 (44%) in rural areas.
Over the studied years, the percentages on urban and rural areas have registered variations of about 10%; for example, in 2011, 52.68% of people presenting avoidable death were from urban areas and in 2013, this share was of 63.10% (table no.4, figure no. 1).
Table no. 2. Annual distribution of avoidable deaths by gender of the deceased in the period 2006-2015
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total
Men 103 94 86 92 78 92 99 88 98 98 928
78.78%
Females 30 27 33 21 20 19 24 15 29 31 250
21.22%
Total 133 121 119 113 98 111 123 103 127 129 1178
Table no. 3. The average age of victims of annual avoidable deaths, 2006-2015
Year Average age (years)
Standard deviation
Standard deviation
95% confidence interval of the difference Minimum/maximum age (years)
Lower Upper
2006 45.65 ±15.896 1.378 42.93 48.38 2/80
2007 46.68 ±14.406 1.310 44.08 49.27 17/82
2008 47.61 ±15.520 1.423 44.80 50.43 2/80
2009 45.69 ±15.603 1.468 42.78 48.60 0/84
2010 49.78 ±15.820 1.598 46.60 52.95 1/80
2011 49.12 ±16.716 1.579 45.99 52.25 0/89
2012 49.33 ±14.115 1.273 46.81 51.85 2/74
2013 51.00 ±16.122 1.589 47.85 54.15 0/89
2014 50.98 ±15.857 1.407 48.19 53.76 0/85
2015 50.87 ±14.442 1.272 48.35 53.38 0/84
Total 48.63 ±15.515 1.452 47.74 49.52 -
Table no. 4. Annual repartition of forensic avoidable deaths according to the area of origin of the victim
Year Urban Rural
No. % No. %
2006 72 54.13 61 45.87
2007 68 56.20 53 43.80
2008 69 57.98 50 42.01
2009 62 54.87 51 45.13
2010 56 57.14 42 42.86
2011 59 52.68 53 47.32
2012 66 53.66 57 46.34
2013 65 63.10 38 36.90
2014 71 55.90 56 44.10
2015 71 55.04 58 44.96
Total 659 55.94 519 44.06
Figure no. 1. Annual repartition of forensic avoidable deaths according to the area of origin of the victim
Further on, we have divided avoidable deaths according to the place of occurrence of death, so we used three categories: “at home” - for the deaths which occurred at home;
“at hospital” - for the deaths occurred during hospitalization or in the emergency rooms; “Other” - for deaths produced in locations other than those mentioned above. Through this analysis, we found that more than half (57.39%) of the forensic avoidable deaths were classified as “other”. At home, there occurred 289 (24.53%) avoidable deaths, while at the level of medical units, 213 (18.08%) (table no. 5).
Table no. 5. Distribution of forensic avoidable deaths according to the place where death occurred, in 2006-2015
Place of death At home
At hospital
Other Total
Avoidable deaths
no. 289 213 676 1178
% 24,53 18,08 57,39 100
Another parameter aimed at in the study was the time of death. In this regard, we classified avoidable deaths according to the season in which they were produced. Most avoidable deaths have occurred in autumn (28.18%) and summer (27.50%). At
the opposite pole, the fewest avoidable deaths were recorded in spring (20.88%).
The small difference between the number of avoidable deaths produced in autumn and summer has been relatively constant over the study period, occupying alternatively the first place (table no. 6).
Table no. 6. Seasonality of avoidable deaths from the forensic cases, 2006-2015
Year Number of avoidable deaths Winter Spring Summer Autumn
2006 32 23 45 33
2007 31 27 29 34
2008 26 29 27 37
2009 24 26 33 30
2010 20 14 28 36
2011 29 18 28 36
2012 28 31 30 34
2013 28 23 29 23
2014 27 27 42 31
2015 31 28 33 38
Total 276 246 324 332
Of the 1178 avoidable deaths identified in forensic casuistry of Sibiu County, in 2006-2015, less than 40% (495 of avoidable deaths) were classified as violent death, the main subject of the forensic activity; this category includes, in particular the deaths due to motor vehicle accidents and iatrogenic deaths. The other 58%, i.e. a total of 683 of avoidable deaths that have benefited from forensic autopsy belonged to the category of non-violent deaths (figure no. 2).
Figure no. 2. Distribution of avoidable deaths according to the type of death, 2006-2015
42.02%
57.98%
Non-violent death Violent death Distribution of casuistry according to the cause of avoidable death identified a predominance of avoidable deaths due to cardiovascular disease, namely a total of 572 avoidable deaths by these disorders, which represent about half of all analyzed cases. Avoidable deaths due to accidents caused by motor vehicles are also common, respectively 488 cases (41.42%). A significantly smaller number of avoidable deaths, namely 118 cases were due to other diseases included in the list of avoidable deaths presented in the first trial research. Thus, in the category of “other”, we included the following diseases that caused avoidable deaths, discovered during the forensic autopsies performed in Sibiu County: hepatic cirrhosis, various forms of pulmonary tuberculosis, lung cancer, gastric/duodenal ulcer, pneumonia, therapeutic accident (only one case in ten years analyzed) and nephritis/nephrosis (table no. 7).
Table no. 7. Distribution of avoidable deaths according to the cause of death, 2006-2015
Cause of death Cardio-
vascular Road accidents Other
Avoidable deaths
No. 572 488 118
% 48.56 41.42 10.02
DISCUSSIONS
Generally, avoidable deaths are not the subject of forensic autopsy, except for those due to traffic accidents, which are included in the category of violent deaths and benefit necessarily from autopsy. All the other causes of avoidable death (acute myocardial ischemia, cerebrovascular disease, cirrhosis, tuberculosis, malignancies etc.) typically cause non-violent deaths and are related to family medicine or anatomical pathology and only under certain conditions, they become medical-linked cases.(11,12) Thus, the results of this study through which we identified the phenomenon of avoidable death in the forensic casuistry of Sibiu County in the period 2006-2015 do not represent the total of the avoidable deaths at the level of Sibiu County within the study period. We mention this in order not to cause confusion concerning a false underreporting of the phenomenon.
About half of the autopsies performed within the Forensic Service of Sibiu County and Mediaş Forensic Office in the ten years of study addressed avoidable deaths (40.19%);
Their annual average is 118 avoidable deaths per year.
Dynamic analysis showed increases in the share of avoidable deaths in total forensic autopsies, so in 2006 it was 37.25%
and in 2015, it was 43.00%. These percentages confirm the importance of identifying and researching this phenomenon in forensic casuistry.
Greater predominance in males of avoidable deaths resulting from the literature is also confirmed in the case of deaths with forensic consequences; over three quarters (78.78%) of these occurring in men.
In general, the share of men is higher in forensic casuistry, because, on one hand they are more exposed to risk factors that cause a violent death, and secondly addressing health services, especially addressing the family doctor is less, therefore, without periodic evaluations and without any evidence of pathology in the case of a death at home, the family doctor cannot issue the Certificate of the Fact of Death, autopsy being required.(13,14)
The average age of those who ended by an avoidable death was 45.65 years in 2006, respectively 51 years in 2013.
We underline the increasing average age of victims of avoidable deaths, explained perhaps by raised life expectancy, but also by improving the performance of the health system, both primary prevention and the secondary prevention.
The share of victims of avoidable deaths with forensic implications coming from rural areas is higher than that of victims in rural areas (55.94% vs. 44.06%), but the percentage difference is not very important. The predominance of the urban area can be explained by the less healthy lifestyle in cities, higher degree of pollution, greater risk of traffic accidents, higher incidence of neoplasms in the economically developed areas.(15,16) On the other hand, at least theoretically, accessibility to health services and medical education levels are lower for those living in rural areas.
In the studied cases, avoidable death occurred in over half of cases elsewhere than at home or in a medical facility (57.39%), which proves the predominant sudden character of
these deaths.
Only 18.08% of all cases have reached a pre-hospital or hospital unit, either voluntarily or brought in by relatives, but without being helped.
Analyzing the seasonality of avoidable deaths with forensic consequences, we found that most of these were produced in autumn (28.18%) and summer (27.50%); first position in the ranking is alternatively occupied by those two seasons. At the opposite pole, spring is the season when fewest avoidable deaths occur.
Of all avoidable deaths with forensic consequences, nearly half were due to cardiovascular diseases (48.56%), which represent the most common cause of avoidable death at international, national and regional level.
A significant percentage of deaths occurred due to traffic accidents (40%); mention must be made that all deaths produced under these circumstances are subject to forensic autopsy. Instead, avoidable deaths due to cardiovascular diseases, the common practice requires that the family physician issues the Certificate of the Fact of Death or performing autopsy by the pathologist for those who died in a medical unit. Therefore, the magnitude of avoidable deaths from cardiovascular cause revealed by this study is lower than in reality.
CONCLUSIONS
• In the forensic casuistry of Sibiu County, 1178 avoidable deaths were identified within 10 years (40% of forensic autopsies). In dynamics, their share of all forensic deaths increased up to 6% (in 2006, 37% of forensic deaths fell into the category of avoidable deaths, and in 2015, the percentage was of 43%).
• A higher frequency of avoidable deaths was recorded in men (about 80% of avoidable deaths with forensic implications occurred in males), the sex ratio male:female
= 3.7:1.
• Over the studied period, the average age of those included in the survey increased by about 5 years (from 45.65 years in 2006 to 51 years in 2015).
• Percentage of victims of avoidable deaths coming from rural areas is higher than that of victims in rural areas (56% versus 44%); the ratio of urban and rural area of origin is 1.27:1.
• More than half of avoidable deaths which were subject to forensic autopsy occurred elsewhere than at home or in a medical unit. Less than a fifth of them occurred in the emergency room or during a hospital stay. Most frequently, avoidable deaths occurred in autumn and spring (60%).
• Cardiovascular diseases, the most common causes of avoidable death nationally and regionally, led to about half of the avoidable deaths avoidable with forensic consequences (about 49%). Another 40% of these deaths were due to traffic accidents, involving violent deaths, for which forensic autopsy is the rule. Hepatic cirrhosis, pulmonary tuberculosis, lung cancer, gastric/duodenal ulcer, pneumonia, therapeutic accident (one case in the ten analyzed years) and nephritis/nephrosis were among the causes of avoidable death within the forensic casuistry of Sibiu County, totalling 118 cases (10%).
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