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.

Levels of haemolysis have no effect on femoral vein post-mortem tryptase levels.

Haemolysis is reported to be an artefact that may alter post-mortem tryptase levels. However, previous studies did not sample peripheral blood using newly standardised methods. Recent studies have shown that some previously recognised peri- and post-mortem confounders can be muted by careful sample collection with first clamping and then sampling the femoral vein. This prospective study investigated the relationship between the degree of haemolysis of the blood samples and femoral vein post-mortem tryptase levels when sampled using this recommended method. Seventy consecutive post-mortem tryptase levels in non-anaphylactic deaths were compared to the degree of haemolysis of these samples, and results showed no significant correlation between them. The mean post-mortem tryptase level was 9.5 µg/L. This study demonstrated that the effects of haemolysis on femoral vein post-mortem tryptase was negligible when the blood was sampled using the recommended sampling method. Future studies on post-mortem tryptase as well as other typically used blood markers in forensics are recommended to adopt this method of blood sampling in routine practice.

[Clinical practice guidelines: juridical and medico legal issues in health care malpractice liability]. / Linee guida: aspetti giuridici e medico legali nella valutazione della colpa professionale in ambito sanitario.

Clinical Practice Guidelines are clinical tools addressed to medical and health professionals and are normally employed to improve quality and safety of diagnostic and therapeutical procedures but may sometimes limit the autonomy of medical and other health care professionals. The adherence to Clinical Practice Guidelines should not be an exclusive step to evaluate the liability and respect of standards of care in case of medico-legal investigations being each clinical case very specific. Medical liability and respect of standards of care should be evaluated with the support of Clinical Practice Guidelines and the extensive examination of all specific features, professional background and experience requested to treat each single patient.