MEDICO LEGAL

INVESTIGATION OF DEATH
&
DETERMINING CAUSE OF DEATH
DR ZURAIDA MD ZAINURI
Ketua Jabatan Perubatan Forensik
Jabatan Perubatan Forensik
Hospital Sultanah Nur Zahirah
Inquiries of death
S 329 Criminal Procedure Code
Police officer investigate an apparent cause of
death and what manner that death has taken
place.
Those types of death are:
• Suicide
• Killed by another, or animal or machinery or by
accident
• Suspicious circumstances
• Body found dead and death is unknown
• Sudden death
 Death in Emergency Room
• Brought in Dead Body (BID)
• Patient declared dead in the department (DID)
• Patient died just after admitted to the wards
or while in transit to the wards

Most cases History and medical records often

are not known or information are scarce.
 Brought in dead cases (BID)
• All BID’s should be reported to the police
• Paticularly those BID’s brought by persons
other than the police.
• Whether or not the cause of death is known.

Why?
 All Brought in Dead (BID)
• 1st hand history from the patient not available
(Obvious reason. Patient already dead)
• History obtained inadequate or hearsay
• Doctor has not examined or has not
investigated the patient during life.
• Cause of death and the manner of death are
not objectively known or determined
Deaths require police
investigation
• Sudden death cause is unknown
• Body found dead
• Death result from accident - MVA,
animal, persons, machinery etc
• Death caused by someone
• Death from violence or criminal act or
omission
• Death suicides, poisons
Power to order or prevent
forensic post mortem
Police (sergeant and above) within
jurisdiction
Magistrates or higher (within the
jurisdiction)

 Wakil rakyat/ Member of Parliament

 Doctor
 Waris or busybodies
 What happens after the police report has
been made?
• The police officer usually with the rank of a
Sergeant or above will conduct the
investigation under S329 (duti of police
officer to IX the MOD) CPC
• The police will decide whether to issue a post
mortem examination request form or not.
 What will the police do?
Body brought to hospital

Police Officer rank Sgt and above

Use S 330 CPC Not Invoke S 330 CPC

Issue Polis 61 Issue burial permit & fill up Death Cert. Form
The police officer may not issue P61 Form

• The Cause of death will be determined by the

police officer
• The Police Officer shall issue the Death
Certification Form (LM03 Form)
• The Medical Officer may be asked by the
police for assistance.
 What form of assistance the attending
doctor could give?
• Obtaining and provide whatever relevant information
on the circumstances of death
• Examine externally to ensure there are no obvious
external injuries or abnormalities on the body.
• May provide some kind of a signed memo or
statement when required by the police officer, but
only limited to the above information and findings.
 But do not
• Issue or sign the Death Certification Form (LM03)
• Write any Medical Report or Statement to the police
pertaining to the Cause of Death

* All the above must be carried out by the Police

Officer.
When the Police Officer issue the P61 Form

• That means the police has invoke S330 CPC

• The police has requested for a post mortem
examination.
• A magistrate has ordered the post mortem
examination
P61 Form
 S 330 Criminal Procedure Code
If a police officer has reasons to believe or
suspects that death is
• Sudden
• Unnatural Manner
• Death by violence
• Death by Unlawful act or omission
Nearest Government Medical Officer
Nearest government hospital for post mortem examination by
a Government Medical Officer
Provided that if that Officer is satisfied as to the cause of
death and the deceased came by his death by accident he
may order the body to be buried.
 Once the police has issued P61 Form
• The doctor must examined the body and
decide on the extent of the examination
whether to dissect or not. The power to
decide whether to just examine externally or
proceed with the internal examination and
taking any specimens from the body is vested
to the doctor.
• Based on S330 and S331 CPC.(practicable &
extend to dissection)
• If the doctor is at a private hospital. It’s the
duty of the police officer to send the body to a
nearest government hospital for the post
mortem examination by a Government
Medical Officer.
• The doctor after conducting the post mortem
examination, shall then do the followings:-
• Determine the Cause of Death (S328 CPC)
• Issue or make to issue Burial Permit, LM02
and LM10 Form
 Government Medical Officer
• A Registered Medical Practitioner (S14 Medical Act
1971) who is employed by the Government of
Malaysia to work in a government hospital or health
facility include public universities.
• Any Medical Officer must conduct a post mortem
examination when ordered by a magistrate or
requested by the police. (Bab F Perubatan Perkara II
Tanggungjawab Pegawai Perubatan, butiran 10-17,
ms217-219.)
• S34(C) Medical Act 1971 –A Medical Practitioner
authorized by the DG to be deemed a Govt. Medical
Officer
1. The DG may authorized in writing any fully
registered medical practitioner not in public
service to undertake any of the following
functions ie
a) Ex, Ix, Rx/Mx any patients or
b) Perform an autopsy or post mortem
examination of any deceased person
2. …. Shall be deemed a Govt. Medical Officer for
the purpose of CPC or any relevant laws in
Malaysia.
S 331 Criminal Procedure Code
S 331(I) A Government Medical Officer
as soon as practicable make a
post mortem examination.

S 331(II) If necessary to ascertain the

cause of death shall extend
the examination to the
dissection of the body and the
analysis of any portion of the
body.
S 332 Criminal Procedure Code

Transmit a report certifying the cause of

death and conclusions to the police
officer in charge.

The report and anything relevant shall

be admissible as evidence and shall be
prima facie evidence of the facts at any
inquiry.
Registration of Birth and Death Act
1957

S 22 Every registered medical practitioner, the

last in attendance of the deceased must
register his or her death within 12 hours
S 23 Report within 12 hours after a post
mortem examination
S 22 Any medical practitioner can refuse to
sign the death certificate if he suspects
that death was from an infectious
disease and not satisfied with any
diagnosis written, unless the problem
has been rectified.
 Prevention and Control of Infectious Disease Act
1988
S 16 An authorized officer may order any
person who died of an infectious
disease to be conveyed to such
appointed place to be examined.

S 17 Only the authorized person can give

direction on manner of burial or
cremation.
Applies only to patients who died from infectious diseases .
Only stated the person to be examined, nothing said about post
mortem dissection/autopsy/internal examination.
Authorized person = DG or person authorized by DG eg MOH,
State Health Directors or Hospital Directors.
 Destruction of Disease- Bearing Insects Act 1975
S 10(1)c The Director General or a
Medical Officer of Health may-
Cause a post mortem examination
to be made on any corpse where
death is suspected to have been
caused by any insect-borne
disease.
S 10(2) Any person having custody of
any corpse who refuses or
obstructs the post mortem
examination shall be guilty of an
offence and liable to a fine not
exceeding RM 2000.

Applies only to patients who died from Vector borne diseases.

 How we investigate death?
Death

Clinical Control Destruction S 330

Cause
post of of Disease Criminal
known
mortem Infectious Bearing Procedure
Clinical,
Consent Disease Insect Act Code
records & Ix
Act 1988 1975 Police
S 16 S 10(1)C report
 Forensic Consultation
1. Homicides
2. Suicides
3. Body found dead- cause is unknown and/unidentified
4. Unwitnessed accidents - hit and run
5. Child death not certified
6. Maternal death not certified
7. Young adult <45 years not certified
8. Suspicious circumstances
9. Medical/surgical procedures/treatment
10. Potential litiginous
11. Multiple deaths >4
12. Skeletal remains
13. All Poisoning
14. Death in custody cause not certified
15. Potential Tissue and organ donor
16. Notifiable infectious disease
17. Unascertained cause after you have opened up
 Mandatory forensic consultation
• Homicides
Body found with injuries of sharp
weapon, blunt trauma, gunshot etc
• Child death
suspected child abuse
BID with no apparent cause
• Unascertained young adult with no apparent
cause.
• Mass disaster/multiple death
• Exhumation
Determining the Cause of Death
 CAUSE OF DEATH
• What is meant by cause, manner and
mechanism of death?

• What is the cause of death?

The cause of death is simply that disease or
injury which kills a person.
• The concept is between proximate and
immediate cause/ causes of death
• Proximate cause of death is that a disease
or injury initiating an uninterrupted series
of events which ends in death.
• Immediate cause of death is an intervening
disease or injury which results in death at a
particular time and place.
• Dependent or independent of the
proximate cause of death.
• MECHANISM OF DEATH
The physiological derangement produced by
the cause of death which results in death.
• MANNER OF DEATH
An opinion based on known facts concerning
the circumstances leading up to and
surrounding the death in conjunction with the
findings at autopsy and the laboratory tests
 Cause of death
• ICD 9 Classification or ICD 10
• S328 CPC – Meaning of “cause of death”
-include not only the apparent COD as
ascertained by inspection/post mortem
examination, but also all matters necessary to
enable an opinion to the manner of death &
as whether in any way from any unlawful act
or omission.
Registration of Birth and Death Act 1957
S 22 Any medical practitioner, the last in
attendance of the deceased must
register his or her death within 12
hours
S 23 Report within 12 hours after a post
mortem examination
S 22 Any medical practitioner can refuse
to sign the death certificate if he
suspects that death was from an
infectious disease and not satisfied
with any diagnosis written, unless
the problem has been rectified.
Cause of death
Ia. Immediate cause-
intervening disease or injury which
results in death at a particular time and
place.

Due to /consequence of

b. Proximate morbid condition -

a disease or injury initiating an
uninterrupted series of events which
ends in death.

II Other significant condition contributing

to the death but not related to the
disease or condition causing it
 Beware doctors!
Certifying death
- cause of death based on facts,
standard = diagnosis of diseases
- Medical cause of death
possible
Satisfied yourself
Actual cause based on clinical or
autopsy
- Responsible to whatever action taken &
cause given

2/23/2019
 Manner of Death
• Natural
• Unnatural
- Accidental
- Self Harm (Suicide)
- Misadventure
- Homicide – Murder/Manslaughter
Causing Death from
negligence
- Unascertained
 Case 1
• A man BID to casualty with gunshot
wounds to the abdomen. Autopsy showed
intra-abdominal injury with ruptured liver
and damaged intestines
• Cause of death
1a. Intra-abdominal injury
due to
b. Gunshot/Firearm
• Cause of death
1a. Gunshot to the abdomen
 Case 2
• A man brought to the to casualty with
gunshot wounds to the abdomen.
Emergency laparotomy showed intra-
abdominal injury with ruptured liver and
damaged intestines. Operated. But in ICU
he succumbed to septicaemia. Autopsy
done showed peritonitis and
bronchopneumonia.
 Case 2 (contd)
• Cause of death
1a. Peritonitis with
bronchopneumonia

as a consequence of

b. Gunshot wound to the

abdomen
• The immediate causes (1a) are expected, reasonable and
forseeable train of complications from any gunshot wound
to the abdomen (proximate morbid 1b).
• The manner of death is still homicide albeit lesser degree.
 Case 3
• A man admitted with gunshot wounds to the abdomen.
Emergency laparotomy showed intra-abdominal injury
with ruptured liver and damaged intestines.
Operated.During recovery he collapsed and died from
AMI. Autopsy showed AMI and coronary artheroma,
others OK.
• Cause of death
1a. Acute myocardial infarction
due to
b. Coronary artery
arterosclerosis
• Manner of death is natural. The assailant may be charged
with grievious bodily hurt or other firearms offences.
 Case 4
• A man brought to the to casualty with gunshot wounds to
the abdomen. Emergency laparotomy showed ruptured
liver and damaged intestines. Part of the liver resected.
Intestines repaired. But accidentally aorta was cut and
bleeds profusely and died.
• Cause of death
1a. Aortic injury/Cut aorta
due to
b. sharp object or instrument injury
• This is definitely perioperative death, but manner?
Natural?, accidental?, homicide?
• Homicide who?
• “ Novus actus interviniens”
• “ Res ipsa loquitor”
 Case 5
• A patient admitted with PUO, investigation nothing
fruitful, eventually died.
• Cause of death?
1a. Fever unknown origin?
• Ideally ask for consent for clinical post
mortem. Usually refused.
• Think of the unthinkable!
• Use S329 CPC. Police open SDR report.
Medicolegal post mortem
• Autopsy failed to find anything
• Cause of death
1a. Fever , cause unascertained
 Case 6
• A patient admitted with injuries to the head due to MVA.
CT Scan showed SDH, SAH and massive cerebral injuries.
• Cause of death ?
• Need Post mortem?
• Cause of death
1a. Head injury
due to
b. MVA
• Post mortem.
Yes, the police will issue Police 61, but attending doctor
not need to dissect, external examination suffice,
provided all the circumstances known.
• DO NOT report mechanistic terminal events such as:
cardiac arrest
asystole
cardiopulmonary arrest
respiratory arrest
electromechanical dissociation
ventricular fibrillation
• DO NOT report symptoms or signs.
• DO NOT oversimplify
• DO NOT use abbreviations
 Death certification
• Sudden Natural death cause unascertained
• Sudden death pending laboratory
investigation
• Sudden Natural death pending
histopathological investigation
• Sudden death cause undetermined
 Death cause unascertained

• Refer to a pathologist for post mortem

• Blood samples – serology, haematological,
biochemical if death < 6 hours
• Send all samples collected, ante or post
mortem
• Trace all records & results
 Death cause unascertained
• Full autopsy
• Biochemistry samples – urine,vitreous fluid
for Urea, Na, Cl, K, Glucose
• Microbiological – Blood Culture, swabs,
tissue swabs for viral studies
• Toxicological – blood, urine, bile fluid,
stomach content, tissues in plain containers
• Histopathological – tissues, specific organs,
consider keep in deep freezer
Burial Permit
 Borang JPN. LM. 03
(DAFTAR KEMATIAN)
 Borang JPN. LM09/ LM10
(PERAKUAN PEGAWAI PERUBATAN MENGENAI SEBAB KEMATIAN)
 References
• Criminal Procedure Code (FMS Chap 6)
• Prevention and Control of Infectious Diseases Act
1988 (Act 342)
• Destruction of Disease Bearing Insect Act 1975 (Act
154)
• Medical Act 1971
• Legal Aspect of Medical Practice, Knight B, Churchill
Livingstone, London, 1992.
• Pathology of death in pregnancy, Toner PG & Crane J,
Recent Advances in Histopathology 16, 1994; 189-
212.
• Perintah-Perintah Am Dan Arahan Pentadbiran, 217-
219
Thank You