A protocol is a signed document containing a written record which can be used
as proof for something when required. An Autopsy Protocol is a document
containing a written record of autopsy findings which can be used as proof for
cause of death, manner of death, and time elapsed since death. It is in reality
a word picture to help the reader visualize what has been seen at autopsy and
how the conclusions have been arrived at. Accordingly, it must contain all the
positive and important negative findings.
An Autopsy Protocol can be prepared in several ways depending on the facilities
available. Details of the examination can be taken down verbatim by an
assistant. In the absence of an assistant, a small pocket tape recorder is very
valuable for recording observations. In a complicated case, it is desirable to
wait till the autopsy is over and photographs are available.
This enables an orderly description of all autopsy findings. Whatever method one
may use, the end result should be an accurate, complete and objective record of
all autopsy findings, without missing anything of importance, and from which
legally valid conclusions can be drawn regarding the information generally
required, viz, cause of death, manner of death and time elapsed since death. The
medical officer should remember that he may have to explain his findings and
opinions in a court of Law under a cross-examination.
The Autopsy Report should be prepared in simple English in a readable form
without using technical jargon whenever possible. It should be self explanatory.
Where the report is likely to be the subject of the criminal or civil
proceedings, it should be prepared in good detail so that the ultimate
conclusions unfold themselves as a logical consequence of observations made at
As a rule, an Autopsy Report should normally contain data regarding preliminary
external examination, including findings at the scene;
internal examination with special reference to detailed examination of stomach
and its contents;
special examinations and investigations; and opinion.
The following general scheme offers important guidelines for a beginner. Every
medical officer will develop his own scheme in due course.
The report should state the Authority ordering the post-mortem; the name of
the deceased; the date, place and time the body was received; the date, place
and time of commencing and completion of autopsy; and the name of persons
identifying the body or the means by which the body was identified. An overall
account of external examination including findings at the scene, a list of
clothing and their condition, and a detailed description of injuries including
their age is given.
The details are recorded in an orderly manner indeed numbered headings with
special reference to photographs or sketches of I’ds that are prepared. The
presence or absence of injuries noted at the inquest is specifically mentioned.
This is followed by a complete description of internal examination. This part of
the report contains detailed description of stomach and its contents and general
condition of the other viscera. Irrelevant and unimportant descriptions of
organs are avoided.
While performing microscopic studies or special examinations like radiography,
the findings are recorded. Details of samples, tissues and organs removed and
preserved are also recorded at this stage.
The core of a medico-legal Autopsy Protocol is really the evidence as regards
cause of death, mainly violence and poisoning. Therefore, all the injuries
should be numbered and summarized at the end in one coherent paragraph to
provide an overview of the entire injury pattern. Any evidence of poisoning
should be similarly recorded. Any disease, if present, should be described in a
separate paragraph specifically, along with its role, if any, in the causation
This is followed by conclusion as to:
(1) cause of death
(2) manner of death, and
(3) time elapsed since death, based, as far as possible, on the autopsy
findings. Photographs, diagrams, weights and measurements provide an objective
There should be no confusion between the cause and manner of death. The cause of
death means the condition or disease that brought about the termination of life.
The manner of death must fall within any one of the five categories, viz,
natural, suicide, homicide, accident or undetermined.
A few examples illustrate this point:
(a) Cause of Death: ischaemic heart disease;
Manner of Death: natural
(b) Cause of Death: incised wound of the wrist, self-inflicted (hesitation
Manner of Death: suicide
(c) Cause of Death: asphyxiation by throttling;
Manner of Death: homicide
(d) Cause of Death: shock and haemorrhage due to multiple fractures, run over by
Manner of Death: accident
(e) Cause of Death: indeterminate- no disease, no injury, no poisoning,
Manner of Death: undetermined.
Opinions regarding the cause of death should be concise and clear. It should not
include any non medical facts or discussion.
As for example, I am of the opinion that Mr. ABC, a well nourished young man
of 25, died of a stab injury in the left chest in the fourth intercostal space
caused by an ice pick which penetrated the heart and resulted in cardiac
tapenade. No natural disease was found at autopsy. If the opinion is based
on the statement of the police or history of the case, this fact should be
mentioned in the report.
As for example, From the history of the case, I am of the opinion that death
was due to failure of the heart caused by a blow on the abdomen. If death is
due to natural causes, this should be specifically stated.
As for example, I am of the opinion that Mr. XYZ, an 82 year old man, died as
a result of coronary thrombosis caused by gradual narrowing of the small
arteries that supply blood to the heart. No injuries of significance were found
at autopsy. Other conditions contributing to death should also be mentioned.
The opinion is given in the form of a certificate by filling all its columns.
This should be followed by the signature, qualifications and designation of the
The Certificate about the cause of death is issued within 24 hours after
conducting the autopsy. In cases of poisoning, in decomposed bodies and/or when
the cause of death requires further examination, such as chemical or
microscopic, the opinion as to the cause of death is reserved pending such
examination. When the result of such examination is known, the opinion regarding
the cause of death is furnished.
In some cases, in spite of a thorough post-mortem examination, chemical analysis
and microscopic examination, the cause of death cannot be arrived at. It is only
such circumstances, that the medical officer is justified in mentioning the
cause of death as undetermined, and the manner of death also undetermined. The
investigation officer may still proceed with the case, if he so desires,
depending on the circumstantial evidence.
Autopsy Protocol is a vital and most relevant record of the cause of death
and/or unnatural termination of life and hence, the greatest and the minutest
care should be undertaken while making the Autopsy Report.
Written by: Navin Kumar Jaggi and Gurmeet Singh Jaggi