Fentanyl-Related Deaths in Ontario, Canada: Toxicological Findings and Circumstances of Death in 4395 Cases (2020-2022).

Over the last 20 years there has been a significant increase in fentanyl related deaths in Ontario, Canada. This report examines toxicological findings in a series of death investigations in which fentanyl was quantitated to identify the prevalence, trends and demographic data associated with fentanyl in Ontario, Canada, and to highlight the changes in these trends since fentanyl began appearing in casework in Ontario in the early 2000s. A retrospective study of all cases in which fentanyl was quantitated in blood, using liquid chromatography-tandem mass spectrometry, was conducted for the time period between January 1, 2020, and December 31, 2022. A total of 4395 cases were included, 77% of the decedents were male and 23% were female with ages ranging from 0 to 95. The most frequently classified cause of death was mixed drug toxicity (69%) followed by fentanyl intoxication at 19%. Less than 10% of cases where fentanyl was quantitated were classified as non-drug related deaths. Fentanyl concentrations in all cases ranged from 1.3 to > 2000 ng/mL. Other drugs were frequently detected with fentanyl. In mixed drug toxicity cases, stimulants were the most frequently encountered class of drugs: cocaine was identified in 51.8% and methamphetamine was observed in 43.0% of cases, respectively. Detailed reports for select cases were included to provide additional insight into the different case types and to show the difficulty in interpreting blood concentrations without additional detailed case histories. This study provides valuable information for the scientific and medical community regarding the continued use of fentanyl and how patterns of fentanyl use have evolved since it began to appear in forensic casework.

Rare case of multiple self-inflicted gunshot wounds to the chest in Poland.

Multiple gunshot suicides are relatively rare and present significant challenges for investigators and forensic pathologists. In such cases, assessing the possibility of more than one shot being fired can be crucial in distinguishing homicide from suicide. We present a rare case of multiple self-inflicted gunshot wounds to the chest with severe injury to the heart and left lung. Both the sudden, unexpected death of the man, the unknown source of the firearm, and the number and nature of the injuries sustained seemed quite unusual. The investigation revealed that the wounds were self-inflicted at close range, and the interval between successive shots (estimated by witnesses at up to 2 min) suggests that even multiple gunshot wounds perforating the heart and lungs may not necessarily cause immediate incapacitation. Forensic investigations in such cases should be multi-faceted and include full autopsy and ballistics expertise, as well as witness testimony and medical history.

Cause and Manner of Death of a Skeletonized Cadaver: Meeting Some Challenges.

Cause of death is defined as a natural disease or injury that led to physiologic changes resulting in death. Manner of death refers to the circumstances surrounding death. Decomposition, especially in advanced stages, creates difficulties in post-mortem examination for it encompasses the processes that lead to the loss of important observable findings and features. Traumatic injuries observed in decomposed cadavers might be analyzed by their vital features and significance for the occurrence of fatal outcomes that help determine the cause and manner of death. An almost fully skeletonized cadaver was admitted to the Department of Forensic Medicine and Deontology at The Medical University, Sofia, Bulgaria. Along with the obligation to answer the post-mortem interval, what were the anthropological and biological features, the cause and manner of death had to be determined in order to classify the case as criminal or not. The cause of death was established by the morphological finding - gunshot injury of the head, passing the brain. The manner of death remained undetermined because of the absence of soft tissues in the areas of the injuries. It was concluded that there was no sufficient forensic data to answer if it was suicide, homicide, or even an accident.

Reliability in distinguishing murder from accidental event with current forensic criteria in traumatic head injury.

Discovering a body displaying signs of multiple head trauma requires a thorough examination by the forensic pathologist, and a multidisciplinary approach is recommended. However, determining the manner of death is not always possible. We present a case in which the body of a 60-year-old man was discovered lying face down on the floor of his apartment, partially unclothed, surrounded by blood and vomit, and presenting numerous head injuries. The autopsy concluded that the cause of death was a result of post-traumatic brain injury. Nevertheless, applying current criteria made it challenging to ascertain whether the trauma stemmed from an accidental event or an assault.

Differentiating suicide from homicide in sharp-force fatalities with stab and/or incised wounds: A scoping review.

The majority of sharp-force fatalities with stab and/or incised wounds are homicides. However, suicidal sharp-force fatalities with stab and/or incised wounds are also reported. Thus, distinguishing suicidal stab and/or incised wounds from homicidal stab and/or incised wounds is significant from the forensic perspective. This scoping review primarily summarizes the existing research findings on the differentiation of suicide from homicide in sharp-force fatalities with stab and/or incised wounds. The literature was systematically searched on February 28, 2023, using the PubMed database. A search string formed by a combination of keywords related to suicide, homicide, and stab and incised wounds yielded 23 records. After applying the eligibility criteria, six records/studies met the inclusion criteria and were included in the present scoping review. Results showed that the predictive strength of various parameters, either individually or collectively, in diagnosing the manner of sharp-force fatality as suicide or homicide is not always hundred percent accurate. Some of the important predictors of the homicidal manner of death in sharp-force fatalities include clothing damage, presence of defense injuries, presence of injuries caused by another type of violence other than sharp-force, vertically oriented chest stabs, and sharp-force injuries in the head and back anatomical sites. Some of the important predictors of the suicidal manner of death in sharp-force fatalities include the presence of tentative injuries, sharp-force injuries to the wrist, and the presence of a suicide note.

Commentary on "Fatal cardiac air embolism after CT-guided percutaneous needle lung biopsy: medical complication or medical malpractice?"

To differentiate between medical malpractice and expected, but rare, medical complication in a medicolegal autopsy context is often difficult. Such an assessment requires knowledge about the clinical practice associated with the procedure at hand, and that findings of the autopsy, including medical relevant information such as patient chart, radiological imaging, and statements from witnesses about the medical procedure itself, provides evidence that substantiate either conclusion. In a case report published in the journal such an assessment is discussed by presenting findings and circumstances surrounding the death of a patient during a percutaneous needle lung biopsy procedure. The authors conclude that the death was not due to medical malpractice. However, in this commentary it is highlighted that the reasoning behind the conclusion needs to be further substantiated.

Homicide, suicide, or accident? Complex differential diagnosis. A case series.

Distinguishing between homicides, suicides, and accidental deaths remains a challenging task. The examination of actual cases, which involve a multitude of variables, significantly contributes to our understanding of these matters. In this context, we present three distinct cases that required the involvement of various specialists to conduct a thorough analysis of the manner of death. In the first case, the integration of on-site inspection, autopsy, radiological, and kinematic data enabled the identification of a homicidal death. In the second case, the combination of circumstantial evidence, autopsy findings, toxicological analysis, and meteorological data revealed an atypical accidental death resulting from an attempted suicide. In the third case, radiological findings, supplemented with criteria from forensic science, indicated an accidental manner of death. In all reported cases, a multidisciplinary approach played a pivotal role in the differential diagnosis of the manner of death.

Autopsy findings in fire deaths in relation to manner of death: Analysis of autopsy records in Friuli, Italy (1993-2020).

The determination of the cause and manner of death can be particularly difficult in burned and charred bodies and autopsy remains a key element in the investigation. In this study, 39 autopsy records of fire deaths were reviewed in relation to the manner of death (25 accidents, 8 suicides, 3 homicides and 3 instances in which the manner of death remained undetermined). The analysis focused on the study of the burns, the degree to which the bodies were consumed by fire and the evidence of signs of vital exposure to fire and of non-fire-related injuries. Total surface body area (TBSA) was found to be significantly higher (p = 0.02) in suicides than in accidents. Moreover, the degree of destruction according to the Crow-Glassman Scale and the presence of a pugilistic posture tended to be higher in suicides compared to accidental deaths, whereas such parameters were found to be variable in homicides. With regard to the anatomical distribution of burns, in contrast with the literature, the feet were affected by burning in all suicides, with a significantly higher prevalence than in accidents (p < 0.01). Traumatic non-fire related injuries were noted in all homicides (with no signs of vital exposure to fire), 1 complicated suicide, 1 undetermined death and 13 accidents. We found that very few studies have focused on the analysis of burn distribution and extension according to manner of death and that there is currently no standardised anatomical model with which to study these variables for forensic purposes.

The Role of Pathological Examination of the Liver in Medicolegal Autopsy: A Tertiary Care Center Study From North India.

BACKGROUND: The pathological examination of a medicolegal autopsy is a great learning opportunity for a pathologist as well as for a forensic expert, where the cause of death remains unknown. Liver disease epidemiology differs from one geographic area to another. MATERIAL AND METHODS: This was a prospective observational study with 100 medicolegal autopsy cases over a one-year period conducted in the Department of Forensic Medicine and Toxicology (FMT) and Pathology. Representative tissue from the liver was collected in 10% neutral buffered formalin and sent for histopathological examination. RESULTS: The mean age of the cases was 41.98 ± 15.39 years, and ages ranged from 20 to 90 years with male preponderance. The most common histopathology and gross findings noted were mild to moderate chronic hepatitis (CH) (54%) and fatty change (36%), respectively. There was a significant association (p ≤ 0.05) between histopathology and gross findings, cause, and manner of death. CONCLUSION: Gross and histopathological examination of the liver in a medicolegal autopsy has a significant role in ascertaining the cause and manner of death.

Caracterización epidemiológica y hallazgos en homicidios por sofocación con bolsas de plástico en la ciudad de Medellín, Colombia 2008-2021 / Epidemiological characterization and findings in homicides due to suffocation with plastic bags in the city of Medellín, Colombia 2008-2021

Introducción el presente estudio describe las características de las víctimas de muertes por sofocación homicida con bolsas de plástico en el período comprendido entre 2008 y 2021, en necropsias practicadas en el Instituto Nacional de Medicina Legal y Ciencias Forenses de la ciudad de Medellín. Materiales y métodos se realizó un estudio descriptivo, retrospectivo, cuya información se obtuvo a partir de los informes de necropsia realizados por médicos forenses de la institución. Resultados de las 38.772 necropsias realizadas, 17.703 fueron homicidios de las cuales 96 (0,54%) fueron debidas a la utilización de bolsas de plástico para producir la muerte. De los 96 casos analizados el 92,7% (89) correspondieron a hombres y el 7,3% (7) a mujeres. La población masculina joven de los 15 a 27 años fue la más afectada; el 74,4% (71) ingresaron como cadáveres no identificados y en el 17,1% (14) fue considerado el diagnóstico de tortura dentro del análisis de la necropsia médico legal. Los hallazgos de sofocación en el examen externo fueron congestión facial 67,1% (55), petequias en las conjuntivas 63,4% (52), petequias en la cara 28,0% (23), lesiones en la mucosa oral interna 61,0% (50) y excoriaciones en las comisuras labiales 25,6% (21) por el uso de elementos extraños en la cavidad oral o la aplicación de maniobras asfícticas. El 58,5% (56) presentaban signos de trauma en otros sitios del cuerpo que no explicaban en sí la causa de la muerte. El 36,4% (35) presentaban bolsas de plástico cubriendo la cabeza y ajustadas al cuello con algún elemento, el 32,3% (31) cinta trasparente adherida a la bolsa plástica que cubría la cabeza y el 31,3% (30) presentaban una película plástica de nombre comercial Vinipel MR. El 76,8% (73) tenían las manos y los pies atados al momento del hallazgo del cuerpo en la escena. Conclusión ... (AU)

Introduction This study describes the characteristics of the victims of deaths by homicidal suffocation with plastic bags in the period between 2008 and 2021, in autopsies performed at the National Institute of Legal Medicine and Forensic Sciences of the city of Medellín. Materials and methods A descriptive, retrospective study was carried out, whose information was obtained from the autopsy reports made by forensic doctors of the institution. Results Of the 38,772 autopsies performed, 17,703 were homicides, of which 96 (0.54%) were due to the use of plastic bags to produce death. Of the 96 cases analyzed, 92.7% (89) corresponded to men and 7.3% (7) to women. The young male population between the ages of 15 and 27 was the most affected; 74.4% (71) entered as unidentified corpses and in 17.1% (14) the diagnosis of torture was considered within the analysis of the legal medical necropsy. The findings of suffocation in the external examination were facial congestion 67.1% (55), petechiae in the conjunctivae 63.4% (52), petechiae on the face 28.0% (23), lesions in the internal oral mucosa 61.0% (50), and abrasions in the labial commissures 25.6% (21) due to the use of foreign elements in the oral cavity or application of asphyctic maneuvers. 58.5% (56) presented signs of trauma in other parts of the body that did not explain the cause of death. 36.4% (35) had plastic bags covering the head and adjusted to the neck with some element, 32.3% (31) transparent tape attached to the plastic bag that covered the head and 31.3% (30) presented a plastic film with the trade name Vinipel MR. 76.8% (73) had their hands and feet tied when the body was found at the scene. Conclusion This is the first step to obtain information on the characterization of individuals and their macroscopic findings related to homicide deaths due to suffocation with plastic bags, to warn about the actions of organized criminal groups and their practices in the transnational ... (AU)

Evaluation of the cardiovascular risk induced by cannabis use from a series of 43 autopsy cases.

The aim of this monocentric observational autopsy study was to confirm the existence of a link between cannabis use and cardiovascular risk. It was based on the analysis of autopsy findings, cardiovascular pathological findings, and toxicological data in 43 autopsy cases of people who died with tetrahydrocannabinol (THC) in their blood over a 2-year period. Hair analysis was performed when available (n = 40) to distinguish between occasional and chronic cannabis use and to take into account other possible exposures, including smoking, drug consumption, and the use of other drugs of abuse (mainly cocaine, heroin, and amphetamine). A statistically significant association (Fisher's exact test, p < 0.001) was found between cannabis use, an undetermined manner of death, and the presence of an arrhythmogenic cardiac condition. An association was also found between cannabis use and the presence of advanced coronary heart disease (p = 0.01), heart disease (including ischemic heart disease, p = 0.003), or cardiomyopathy (p = 0.01). Through its systemic vascular action, cannabis could be a factor in triggering sudden death in subjects with arrhythmogenic cardiac conditions. In view of this finding, the mode of death of subjects who died in the presence of THC in the blood would in most cases be an "accident." These results highlight the potential adverse cardiac effects associated with cannabis use.

Patient termination of a life-sustaining medical device: Suicide or natural death?

Medical technology has made tremendous strides in extending the lives of patients who have suffered organ failure. Machines can now replace the function of the kidneys, the heart, and other vital organs. Much has been written about a patient's right to refuse or direct the withdrawal of medical treatment, especially at the end of life, under the guise of "death with dignity." However, little attention has been paid to the situation where a patient elects to deactivate their life-sustaining medical device without a physician's involvement. This raises the challenging question of whether the patient's manner of death should be classified as suicide or natural. Surprisingly, common law, statutes, medical ethics, and public health practice are not in alignment on the answer. This article will explore the ramifications and far-reaching impact that such divergence has on the survivors and the medical community, as well as recommend corrective actions and practical approaches for the medical and legal practitioner.

The association of Ned Kelly tattoos with suicide and homicide in a forensic context-a confirmatory prospective study.

Ned Kelly, an iconic figure in contemporary Australian mythology, was a bushranger (outlaw) who was executed in 1880 for the murder of a serving police officer, Constable Thomas Lonigan. Kelly is often commemorated by tattoos which depict his armour and helmet or his alleged last words of "Such is life". A study was undertaken from January 1, 2011, to December 31, 2020, at Forensic Science SA, Adelaide, South Australia, of all cases with such tattoos. De-identified case details included the year of death, age, sex and cause and manner of death. There were 38 cases consisting of 10 natural deaths (26.3%) and 28 unnatural (73.7%). The latter included 15 cases of suicide (39.5%), 9 accidents (23.7%) and 4 homicides (10.5%). Of the 19 suicides and homicides, there were 19 males and no females (age range 24-57 years; average 44 years). The number of suicides in the general South Australian forensic autopsy population in 2020 was 216/1492 (14.5%) which was significantly lower than in the study population in which 39.5% of cases were suicides (2.7 times higher; p < 0.001). A similar trend occurred for homicides which accounted for 17/1492 in the general forensic autopsy population (1.1%), significantly lower than in the study population which had 10.5% homicides (approximately 9.5 times higher; p < 0.001). Thus, in the select population referred for medicolegal autopsy, there appears no doubt that Ned Kelly tattoos are associated with suicides and homicides. While this is not a population-based study, it may provide useful information for forensic practitioners dealing with such cases.

Homicidal electrocution disguised as an accidental death.

Deaths due to electrocution are mostly accidental. Homicide by electrocution is rarely reported in the literature. However, the location and pattern of the electrocution wound can raise concern for a possible homicidal manner of death. We are reporting an unusual case wherein the dead body of a middle-aged man was found lying in a suspicious condition on the roadside of desolated area. There were circumferential, grooved electrocution lesions over the left and right second toes with oval electrocution lesions on the medial aspects of both the left and right third toes. There were split lacerations over the right high parietal region, right pinna, and forehead. There was avulsion of the nail of the left thumb. Pressure abrasion was consistent with a ligature mark on the lower part of the left leg. The locations and pattern of these injuries raised the possibility of torture infliction. Death was attributed to electrocution, which was confirmed by histopathology. Autopsy findings and possible inferences were furnished to the police. This case highlights the careful observation of different characterizations and locations of the wounds and deducing inferences about the possible manner of death. This information can be useful to investigating agencies.

Postmortem injury evaluation using the Forensic Injury Severity Score Template (FISST): a preliminary study.

The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are important evaluation tools used in clinical practice to determine the degree of injury in patients with trauma. However, they are not suitable for forensic practice and their use in forensic applications is limited. This study aimed to present a system that can objectively and quantitatively determine the severity of postmortem injuries and that can be applied to forensic medicine. Subsequently, we applied this system to individual postmortem cases and analyzed the injuries identified during autopsy. We performed a retrospective study of 119 autopsies performed between 2018 and 2021. Data were categorized and analyzed using the Forensic Injury Severity Score Template (FISST), a scoring system developed based on the AIS and ISS. The mean FISST scores were as follows: men, 53.6; women, 46.8; 20-65 years old, 55.6; older than 65 years, 41.4; natural death, 13.8; unnatural death, 66.3; and all deaths, 51.8. Statistically significant differences in the FISST scores were found between natural and unnatural deaths, suicidal and accidental deaths, and trauma-related death subtypes. Injuries identified during autopsy can be objectively and quantitatively evaluated using FISST. We suggest that FISST is a useful tool in forensic medicine because it is tailor-made for injury evaluation from a postmortem perspective.

Pattern of deaths in paediatric population- An autopsy based study done at a tertiary care hospital in New Delhi.

The study was done retrospectively at Lady Hardinge Medical College, New Delhi to assess the pattern of Paediatric deaths among total paediatric autopsies conducted from year 2019-2021. All Deaths among the individuals less than 18 years of age were studied and statistical analysis was done. During the three-year study period from year 2019-2021, 41.2% were females and 58.8% were males in total 17 paediatric autopsies conducted in the year 2019. 60% female, 40% male among total 15 cases in the year 2020 and 58.3% female, 41.7% male among total 12 cases of paediatric autopsies conducted in the year 2021. On distribution of number of cases in a particular year of study as per the manners of paediatric autopsy cases conducted from year 2019-2021, 40% accidental deaths were recorded in 2019 and 2020 each. The accidental deaths were recorded in 20% cases in the year 2021 among total cases of paediatric autopsy done. Total number of homicidal deaths recorded was 50%, 12.5% and 37.5% in 2019, 2020 and 2021, respectively. The natural cause of death was in 38.5% cases in the year 2019; 46.2% and 15.4% were died of natural cause in the 2020 and 2021, respectively. Total number of suicidal deaths recorded was 25% in 2019 and 2020 each year and 50% in 2021. Out of total number of cases 23% and 21% were having history of hospital deaths and fall from height, respectively. Out of the total cases of paediatric autopsy done 16% cases each were died due to asphyxia deaths and septic shock. The cerebral damage was cause of death in 14% cases and 11% cases each were died of craniocerebral damage and haemorrhagic shock. The bilateral pneumonitis was cause of death in 7% cases and 5% cases each were died of strangulation, aspiration pneumonia, poisoning.

Emerging issues in the approach to submerged bodies: Water-related deaths in Friuli, northeastern Italy (1993-2020). Analysis of post-mortem reports and some unusual cases.

When analysing bodies recovered from a watery environment, all manners of death, a variety of causes of death and the possibility of body disposal have to be considered. Unclear circumstances of death, unidentified victims and body decomposition may hamper a forensic investigation. The lack of specific and sensitive drowning-related autopsy findings and post-mortem blood alcohol levels (blood alcohol concentrations (BACs)) may also lead to erroneous conclusions. We reviewed the autopsy records for all bodies recovered from water in Friuli, northeastern Italy, over a 28-year period, focusing on death circumstances, autopsy findings and blood alcohol levels. Some unusual cases were examined separately. Among the 69 cases, there were 32 accidents, 13 suicides, 4 homicides, 6 natural and 14 undetermined deaths. Causes of death included 51 drownings, 6 undetermined, 5 cardiac deaths and 7 non-drownings. Six deaths in a bathtub and one diving-related death were also included. Acute alcohol intoxication was ascertained in 22 of 40 victims. Some significant limitations in the approach to water-related deaths have been highlighted: although emphysema aquosum and external foam resulted to be the most reliable indicators, a determination of drowning based exclusively on autopsy findings cannot be ascertained with certainty. Furthermore, it was found that the standard definitions of wet and dry drowning in the literature differ widely from a morphological perspective and this may lead to misleading outcomes. Post-mortem BAC changes have been critically analysed only in bodies found in cold water, and, in the absence of an alternative to blood specimens, the use of pre-set cut-off values is still necessary.

Contextual information in medicolegal death investigation decision-making: Manner of death determination for cases of a single gunshot wound.

To explore the role of contextual information in determining manner of death, four cases involving single gunshot wounds were presented to participants (n = 252) involved in medicolegal death investigation. The participants received identical autopsy information but different contextual information. The data demonstrated that participants tended to rely on contextual information more than autopsy information: In the suicide context, participants across the four cases reached 153 final decisions of suicide (and 25 of homicide), whereas in the homicide context, participants reached only 10 final decisions of suicide (and 181 of homicide) --all while examining identical autopsy information. The impact of the contextual information was so powerful that many participants changed initial autopsy-based conclusions to align with the contextual information. Given the significant role and impact that contextual information has on expert decision making, one must consider what, how, and when contextual information should be used.

Chemical trace XRF analysis to detect sharp force trauma in fresh and burned bone.

Forensic anthropologists may not always be able to differentiate heat-induced fractures from fractures with other aetiologies, namely sharp force traumas, with clear nefarious impact on medico-legal conclusions. The objective of this study was to experimentally investigate if blade chemical traces are transferred to defleshed bone tissue and if they remain there after a burning event. This was accomplished by prompting sharp force traumas in 20 macerated fresh pig ribs with five different instruments, namely a stainless steel knife, an artisanal knife and a ceramic kitchen knife, a small axe and a large axe. Another pig rib was used as control, not being subjected to any trauma. All instruments were probed by X-ray fluorescence (XRF) to establish the composition of each blade. Bone samples, both pre-burned and post-burned (at 500 °C, 700 °C, 900 °C and 1100 °C), were then probed by XRF. All sharp force instruments left detectable chemical traces on pre-burned bone, although not in all samples. Furthermore, traces were still detected after experimental burning in most cases. Potentially, XRF can provide relevant information about the aetiology of fractures in burned and unburned bones, although the effect of soft tissues and diagenesis must still be investigated.

The Magnitude of Medicolegal Postmortem That Turned Out to Be Natural Deaths at the University of Benin Teaching Hospital: A 3-Year Study.

Background: The periodic determination of the degree to which coroner's postmortems done for medicolegal purpose turns out to be natural death is desirable because of its usefulness to health administrators in making policies that may ultimately help in focusing on the prevention/management of the causes of natural death at that particular point in time. Objective: The objective of the study was to determine the causes of natural death by a retrospective analysis of coroner's postmortem cases carried out on patients ages 19 years and above who died from natural causes. Materials and Methods: A 3-year period, retrospective postmortem study was carried out at the Department of Anatomic Pathology, University of Benin Teaching Hospital on 530 medicolegal postmortem cases ages 19 and above who died from natural causes. Results: Natural deaths were observed in 530 cases of medicolegal postmortems. Their age ranged from 19 years to 104 years with a mean age and standard deviation of 52.82 ± 16.71 years. Cardiovascular system diseases were the most common causes of natural deaths with hypertensive heart disease being the most common underlining cause. Infections and diseases of the respiratory, gastrointestinal system/hepatic, central nervous and endocrine systems were also noteworthy. Conclusions: Most causes of natural deaths were in the middle ages with the noncommunicable diseases (NCDs) accounting for a significant proportion. To reduce premature death from NCDs by 2030, the World Health Organization (WHO) is promoting its prevention and management. It is our desire that our health administrators would adopt this WHO model incorporating postmortem-based data for planning of medical services.