Factors associated with autopsy rates in a 6-year sample of Danish suicides in the Capital area of Copenhagen.

On average, two suicides occur in Denmark every day. In order to prevent suicides, it is important to understand their nature. The forensic autopsy plays an important role by providing detailed knowledge of the cause and manner of death. Unfortunately, the autopsy rate for suicides in Denmark is very low. The aim of this study was to elucidate the factors that may affect the decision to perform a forensic autopsy and thereby affect the autopsy rate of suicidal deaths in the Capital area of Copenhagen. Data from 6211 death certificates from the Capital area of Copenhagen, Denmark, over a study period of six years, were investigated. For deaths classified as suicide, the presence of the following factors were registered: gender, age, date of birth, date of death, marital status, nationality, place of death, cause of death, psychiatric condition, former admissions at a psychiatric ward, former attempts of suicide, presence of suicide note, history of substance abuse (alcohol, narcotics or both), and presence of self-inflicted scars. These factors were cross-tabulated with whether a referral to a forensic autopsy was made. Significant association was calculated by using Chi2 and Fisher's exact test. We found a total of 381 cases of suicide. The forensic autopsy rate was 21.3%. The following factors were associated with a significantly lower forensic autopsy rate: age above 50, history of psychiatric illness, the presence of a suicide letter, and cause of death registered as hanging/strangulation/suffocation, drowning/submersion, self-harm with sharp object, and jumping from height. Only the presence of a suicide letter remained significant after the Bonferroni correction for multiple testing. History of substance abuse and cause of death registered as intentional exposure to smoke, fire and flames were associated with a significantly higher forensic autopsy rate. A forensic autopsy can give more precise information on suicide methods, the impact of fatal lesions and comorbidity. Our study results showed that violent methods of suicidal death and psychiatric comorbidity led to a lower forensic autopsy rate. A higher autopsy rate would enable more thorough study and investigation of suicides, which would benefit the next-of-kin, general preventive procedures, and treatment of patients at risk of suicide.

Cost-consequence analysis of cause of death investigation in Finland and in Denmark.

The 1990s 12-16% total autopsy rate in Denmark has until now declined to 4%, while in Finland, it has remained between 25 and 30%. The decision to proceed with a forensic autopsy is based on national legislation, but it can be assumed that the financing of autopsies influences the decision process. Only little is known about the possible differences between health economics of Finnish and Danish cause of death investigation systems. The aims of this article were to analyse costs and consequences of Finnish and Danish cause of death investigations, and to develop an alternative autopsy practice in Denmark with another cost profile. Data on cause of death investigation systems and costs were derived from Departments of Forensic Medicine, Departments of Pathology, and the National Police. Finnish and Danish autopsy rates were calculated in unnatural (accident, suicide, homicide and undetermined intent) and natural (disease) deaths, and used to develop an alternative autopsy practice in Denmark. Consequences for society were analysed. The estimated unit cost (€) for one forensic autopsy is 3.2 times lower in Finland than in Denmark (€1400 versus €4420), but in Finland the salaries for forensic pathologists working at the National Institute for Health and Welfare are not included in the unit cost. The unit cost for one medical autopsy is also lower in Finland than in Denmark; €700 versus €1070. In our alternative practice in Denmark, the forensic autopsy rate was increased from 2.2% to 8.5%, and the medical autopsy rate from 2.4% to 5.8%. Costs per 10,000 deaths were estimated to be 50% (±25%) higher than now; i.e. €3,678,724 (2,759,112-4,598,336), but would result in a lower unit cost for forensic autopsies €3,094 (2,320-3,868) and for medical autopsies €749 (562-936). This practice would produce a higher accuracy of national mortality statistics, which, consequently, would entail higher quality in public health, an accurate basis for decision-making in health politics, and better legislative safety in society. The implementation of this alternative practice in Denmark requires that legislation demands that forensic autopsy be performed if causality between unnatural death and cause of death cannot be clarified or if cause of death remains unknown. The Danish Health and Medicines Authority should provide guidelines that request a medical autopsy in natural deaths where more information about disease as a cause of death is needed. Our study results warrant similar health economic analyses of different cause of death investigations in other countries.

Coding ill-defined and unknown cause of death is 13 times more frequent in Denmark than in Finland.

Exact cause and manner of death determination improves legislative safety for the individual and for society and guides aspects of national public health. In the International Classification of Diseases, codes R00-R99 are used for "symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified" designated as "ill-defined" or "with unknown etiology". The World Health Organisation recommends avoiding the use of ill-defined and unknown causes of death in the death certificate as this terminology does not give any information concerning the possible conditions that led to the death. Thus, the aim of the study was, firstly, to analyse the frequencies of R00-R99-coded deaths in mortality statistics in Finland and in Denmark and, secondly, to compare these and the methods used to investigate the cause of death. To do so, we extracted a random 90% sample of the Finnish death certificates and 100% of the Danish certificates from the national mortality registries for 2000, 2005 and 2010. Subsequently, we analysed the frequencies of forensic and medical autopsies and external clinical examinations of the bodies in R00-R99-coded deaths. The use of R00-R99 codes was significantly higher in Denmark than in Finland; OR 18.6 (95% CI 15.3-22.4; p<0.001) for 2000, OR 9.5 (95% CI 8.0-11.3; p<0.001) for 2005 and OR 13.2 (95% CI 11.1-15.7; p<0.001) for 2010. More than 80% of Danish deaths with R00-R99 codes were over 70 years of age at the time of death. Forensic autopsy was performed in 88.3% of Finnish R00-R99-coded deaths, whereas only 3.5% of Danish R00-R99-coded deaths were investigated with forensic or medical autopsy. The codes that were most used in both countries were R96-R99, meaning "unknown cause of death". In Finland, all of these deaths were investigated with a forensic autopsy. Our study suggests that if all deaths in all age groups with unclear cause of death were systematically investigated with a forensic autopsy, only 2-3/1000 deaths per year would be coded as an ill-defined and unknown cause of death in national mortality statistics. At the same time the risk to overlook unnatural deaths is decreased to a minimum. To achieve this in Denmark requires that the existing legislation on cause of death investigation would need to be changed to ensure that all deaths with unknown cause of death are investigated with a forensic autopsy.

Autopsy rate in suicide is low among elderly in Denmark compared with Finland.

National differences in the legislation on cause and manner of death investigation are reflected in a high autopsy rate in suicides in Finland and a low corresponding rate in Denmark. The consequences for mortality statistics of these different investigation practices on deaths classified as suicides in Denmark and Finland, respectively, are not known in detail. The aim of this article was to analyse autopsy rates in deaths classified as suicides, and to identify any differences in investigation practices in deaths with a comparable cause of death, but classified as unnatural deaths other than suicide. Data from the mortality registries were summarised for the years 2000, 2005 and 2010. Autopsy rates (total, forensic and medical) were analysed with regard to deaths classified as suicide, and they were compared for three age groups (1-50 years, 51-70 years and ≥71 years) and for causes of death. Deaths classified as suicide were compared with other unnatural classifications, and comparable causes of death were coded into six subgroups: poisonings, suffocations/strangulations, firearm discharges, drowning/submersions, explosions/flames and other/unspecified causes. The total autopsy rate for suicides was 99.8% in Finland and 13.2% in Denmark. Almost all of these autopsies were conducted as forensic autopsies. In the age group ≥71 years, Danish suicides outnumbered Finnish suicides (410 versus 283). The total autopsy rate was lower in the more senior age group in Denmark (19.5%, 9.9%, 5.6%), whereas it was consistently high in Finland (99.8%, 99.9%, 99.6%). Among Danish deaths due to poisonings, the autopsy rate was 89.5% when these were classified as accidents, but only 20.7% for cases classified as suicides. The number of deaths in the two Danish subgroups was comparable (550 versus 553). In Denmark, the decision regarding the need, if any, for a forensic autopsy is made during the external forensic examination of the body. Our study showed that the limited use of forensic autopsy to confirm the cause of death in deaths classified as suicides raises doubts about the accuracy of the Danish suicide mortality statistics. Our finding is emphasised by those cases in which the cause of death was registered as intentional self-poisoning. The high number of suicides among the elderly in Denmark is striking and begs further investigation and research. Overall, our data from Finland and Denmark reveal striking differences between the two countries and warrant further comparative studies on the subject in other countries.

[Cystic tumour of the atrioventricular node in a nine year-old girl]. / Cystisk tumor i atrioventrikulærknuden som dødsårsag hos en niårig pige.

Cystic tumour of the atrioventricular node (CTAVN) is a rare type of cardiac tumour. We report a case of a previously healthy nine year-old girl, presenting with syncope caused by complete AV block. Despite intensive treatment, she died of multiple organ failure after two days. Infectious and congenital AV block were ruled out. Histology of the conduction system showed that a microscopic CTAVN was the cause of death. CTAVN is a rare cause of AV block and cardiac arrest, but should be considered in cases of unexplained death.