Management of unidentified and unclaimed bodies: a comparison of model from four countries in the Asia Pacific Region.

Managing mass fatality incidents or disasters involving multiple deaths are not uncommon among forensic practitioners. In fact, management of unidentified or unknown bodies is also a vital component of the day-to-day mortuary work practice. The unidentified and subsequently unclaimed bodies have always been a "silent mass disaster," a problem that needs to be tackled within the forensic community and raises the global issue of ethics, law, and human rights. Unidentified bodies' in Malaysia make up an average of 4.02% of all death cases where a total postmortem examination was performed which is comparable with other developing countries within 4-10% which can go up to 25%. Moreover, unstandardized procedures in all mortuaries in different states and districts in Malaysia have worsened the scenario even with guidelines in place. This study aims to address the issues surrounding unidentified and unclaimed bodies including body disposal from a social and legal perspective using case study methodology by comparing four different countries in the Asia Pacific Region through document analysis and interview methods. One of the major findings is evident in 3 out of the 4 models, whereby there is a considerable gap in consolidating the missing person report and information to match with the unidentified bodies received in forensic institutions in an attempt to enhance the identification process which ultimately intends as a closure for the family members. It is also timely to think out of the box beyond dental records and DNA profiling to improve the identification rate for skeletonized remains through means of anthropology biometrics comparison. With the limited literature published surrounding this domain, it is hoped that the suggestions and recommendations to standardize the management of unidentified and unclaimed bodies can benefit many forensic institutions and public mortuaries in this region.

Use of Post-Mortem Computed Tomography During the COVID-19 Pandemic: The Malaysian Experience.

Background: COVID-19 was declared a pandemic by the World Health Organization (WHO). COVID-19 is highly contagious, making it a threat to healthcare workers, including those working in mortuaries. Therefore, it is important to determine if the cause of death (COD) could be identified using limited autopsy, diagnostic tests and post-mortem imaging modalities instead of full autopsy. This study aims to examine the effectiveness of post-mortem imaging, specifically post-mortem computed tomography (PMCT) at determining the COD during a pandemic. Methods: This cross-sectional study included 172 subjects with suspected or unknown COVID-19 status brought in dead to the institute's mortuary during the pandemic in Malaysia. PMCT images reported by forensic radiologists and their agreement with conventional autopsy findings by forensic pathologists regarding COD were analysed to look at the effectiveness of PMCT in determining COD during a pandemic. Results: Analysis showed that 78.7% (133) of cases reported by forensic radiologists concurred with the COD certified by forensic pathologists. Of these cases, 85 (63.9%) had undergone only external examination and real-time reverse transcriptase polymerase chain reaction (rRT-PCR) COVID-19 testing, meaning that imaging was the sole method used to determine the COD besides history from available medical records and the investigating police officer. Conclusion: PMCT can be used as a complement to medicolegal autopsies in pandemic contexts, as it provides significant information on the possible COD without jeopardising the safety of mortuary health care workers.

Isolated hyoid bone fracture in a child due to a fall.

Hyoid bone fractures due to blunt trauma are rare accounting for only 0.002% of all head and neck fractures with most documented fractures being due to strangulation, hanging, motorcycle helmet straps, sports injuries and rarely as a complication of intubation. However, they are even rarer in the paediatric age group. We present a hyoid bone fracture in a two-year-old child as a result of a fall down three steps. Hyoid bone fractures though generally heal well with conservative treatment must be diagnosed early to avoid air way obstruction leading to morbidity and mortality.

Accuracy and reliability of virtual femur measurement from CT scan.

BACKGROUND: In the application of scientific human skeletal variation in medico-legal matters, virtual anthropology is the current technique performed to examine skeleton and its body parts. Hence, this study was conducted to assess the accuracy and reliability of virtual femur measurement through intra and inter-observer error analysis, and comparison was made between the virtual and conventional methods. METHODS: A total of 15 femora were examined with four parameters i.e. maximum length of femur (FeMl), diameter of femoral head (FeHd), transverse diameter of midshaft (FeMd) and condylar breadth (FeCb). Osteometric board and vernier calipers were employed for the conventional method, while CT reconstructed images and Osirix MD software was utilised for the virtual method. RESULTS: Results exhibited that there were no significant differences in the measurements by conventional and virtual methods. There were also no significant differences in the measurements by the intra or inter-observer error analyses. The intraclass correlation coefficients (ICC) were more than 0.95 by both intra and inter-observer error analyses. Technical error of measurement had displayed values within the acceptable ranges (rTEM <0.08 for intra-observer, <2.25 for inter-observer), and coefficient of reliability (R) indicated small measurement errors (R > 0.95 for intra-observer, R > 0.92 for inter-observer). By parameters, FeMl showed the highest R value (0.99) with the least error in different methods and observers (rTEM = 0.02-0.41%). Bland and Altman plots revealed points scattered close to zero indicating perfect agreement by both virtual and conventional methods. The mean differences for FeMl, FeHd, FeMd and FeCb measurements were 0.01 cm, -0.01 cm, 0.02 cm and 0.01 cm, respectively. CONCLUSION: This brought to suggest that bone measurement by virtual method was highly accurate and reliable as in the conventional method. It is recommended for implementation in the future anthropological studies especially in countries with limited skeletal collection.

Reprint of: Cling film plastic wrap: An innovation for dead body packaging, preservation and transportation by first responders as a replacement for cadaver body bag in large scale disasters.

Cadaver body bags are the conventional method to contain a human body or human remains, which includes the use for storage and transportation of the deceased at any crime scene or disaster scene. During disasters, most often than not, the first responders including the police will be equipped with cadaver body bags to do scene processing of human remains and collection of personal belongings at the disaster site. However, in an unanticipated large scale disasters involving hundreds and thousands of fatalities, cadaver body bags supplies may be scarce. The authors have therefore innovated the cling film plastic wrap as an alternative for the cadaver body bag used at the disaster site. The plastic wrap was tested on six different experimental subjects, i.e. both adult and child mannequins; body parts of the mannequin figure (arm and hand); a human adult subject and an unknown dead body. The strengths of the cling film plastic wrap are discussed in comparison with the cadaver body bag in the aspects of costing, weight, duration of the wrap, water and body fluid resistant properties, visibility and other advantages. An average savings of more than 5000% are noted for both adult body wrap and child body wrap compared to the cadaver body wrap. This simply means that the authors can either wrap 25 adult dead bodies or 80 children dead bodies with the cost of 1 cadaver body bag. The cling film plastic wrap has proven to have significant innovation impact for dead body management particularly by the first responders in large scale disasters. With proper handling of dead bodies, first responders can manage the dead with dignity and respect in an overwhelmed situation to facilitate the humanitarian victim identification process later.

Cling film plastic wrap: An innovation for dead body packaging, preservation and transportation by first responders as a replacement for cadaver body bag in large scale disasters.

Cadaver body bags are the conventional method to contain a human body or human remains, which includes the use for storage and transportation of the deceased at any crime scene or disaster scene. During disasters, most often than not, the first responders including the police will be equipped with cadaver body bags to do scene processing of human remains and collection of personal belongings at the disaster site. However, in an unanticipated large scale disasters involving hundreds and thousands of fatalities, cadaver body bags supplies may be scarce. The authors have therefore innovated the cling film plastic wrap as an alternative for the cadaver body bag used at the disaster site. The plastic wrap was tested on six different experimental subjects, i.e. both adult and child mannequins; body parts of the mannequin figure (arm and hand); a human adult subject and an unknown dead body. The strengths of the cling film plastic wrap are discussed in comparison with the cadaver body bag in the aspects of costing, weight, duration of the wrap, water and body fluid resistant properties, visibility and other advantages. An average savings of more than 5000% are noted for both adult body wrap and child body wrap compared to the cadaver body wrap. This simply means that the authors can either wrap 25 adult dead bodies or 80 children dead bodies with the cost of 1 cadaver body bag. The cling film plastic wrap has proven to have significant innovation impact for dead body management particularly by the first responders in large scale disasters. With proper handling of dead bodies, first responders can manage the dead with dignity and respect in an overwhelmed situation to facilitate the humanitarian victim identification process later.

Effectiveness of bone cleaning process using chemical and entomology approaches: time and cost.

Skeletal examination is an important aspect of forensic pathology practice, requiring effective bone cleaning with minimal artefact. This study was conducted to compare between chemical and entomology methods of bone cleaning. Ten subjects between 20 and 40 years old who underwent uncomplicated medico-legal autopsies at the Institute of Forensic Medicine Malaysia were randomly chosen for this descriptive cross sectional study. The sternum bone was divided into 4 parts, each part subjected to a different cleaning method, being two chemical approaches i.e. laundry detergent and a combination of 6% hydrogen peroxide and powder sodium bicarbonate and two entomology approaches using 2nd instar maggots of Chrysomyia rufifacies and Ophyra spinigera. A scoring system for grading the outcome of cleaning was used. The effectiveness of the methods was evaluated based on average weight reduction per day and median number of days to achieve the average score of less than 1.5 within 12 days of the bone cleaning process. Using maggots was the most time-effective and costeffective method, achieving an average weight reduction of 1.4 gm per day, a median of 11.3 days to achieve the desired score and an average cost of MYR 4.10 per case to reach the desired score within 12 days. This conclusion was supported by blind validation by forensic specialists achieving a 77.8% preference for maggots. Emission scanning electron microscopy evaluation also revealed that maggots especially Chrysomyia rufifacies preserved the original condition of the bones better allowing improved elucidation of bone injuries in future real cases.

Effectiveness of bone cleaning process using chemical and entomology approaches: time and cost

Skeletal examination is an important aspect of forensic pathology practice, requiring effective bone cleaning with minimal artefact. This study was conducted to compare between chemical and entomology methods of bone cleaning. Ten subjects between 20 and 40 years old who underwent uncomplicated medico-legal autopsies at the Institute of Forensic Medicine Malaysia were randomly chosen for this descriptive cross sectional study. The sternum bone was divided into 4 parts, each part subjected to a different cleaning method, being two chemical approaches i.e. laundry detergent and a combination of 6% hydrogen peroxide and powder sodium bicarbonate and two entomology approaches using 2nd instar maggots of Chrysomyia rufifacies and Ophyra spinigera. A scoring system for grading the outcome of cleaning was used. The effectiveness of the methods was evaluated based on average weight reduction per day and median number of days to achieve the average score of less than 1.5 within 12 days of the bone cleaning process. Using maggots was the most time-effective and costeffective method, achieving an average weight reduction of 1.4 gm per day, a median of 11.3 days to achieve the desired score and an average cost of MYR 4.10 per case to reach the desired score within 12 days. This conclusion was supported by blind validation by forensic specialists achieving a 77.8% preference for maggots. Emission scanning electron microscopy evaluation also revealed that maggots especially Chrysomyia rufifacies preserved the original condition of the bones better allowing improved elucidation of bone injuries in future real cases.