Duty of medicolegal examiner in case of death on table

1. DUTY OF MEDICOLEGAL
EXAMINER IN CASE OF
DEATH ON TABLE(DOT)
DR. HARENDRA SINGH BANSAL
JUNIOR RESIDENT
DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY
M. L. N. MEDICAL COLLEGE , PRAYAGRAJ

2. AGENDA
DEATH ON TABLE(DOT)
CAUSES
INVESTIGATION
AUTOPSY
LEGAL RESPONSIBILITY
SUMMARY
DISCUSSION

3. DEATH ON
TABLE(DOT)
Definition:-
They are death associated with anaesthesia
or surgery which occur in the operating room or
before the patient has completely recovered from the
effects of anaesthesia ( usually 24 hours ).
October 16th, 1846, William Thomas Green Morton
demonstrated that diethyl ether could produce
insensibility to pain in a predictable and controlled
manner.
In 1847, Sir James Young Simpson, discovered the
anaesthetic properties of Chloroform.

4. CAUSES
These can be divided into 3 categories
Death due to Anaesthesia Death due to Surgery Death due to diseases
Inexperience of anaesthetist Inexperience of Surgeon Polytrauma
Clinical Factors Air embolism ( m.c. during
neurosurgery)
Severe Electrolyte
Imbalance
Technical Mishaps Massive Hemmorhage IHD
Accidental Perforation of a
viscus
Previous Emboli
Mobilisation
Nosocomial Infections Previous Cardiac Infarct
Adrenal Hypoplasia

5. INVESTIGATION
OF DOT
FORM A TEAM
1. Forensic Expert
2. Anaesthetist
3. Surgeon
4. Specialist of concerned specialty
PRE-SET QUESTIONS
1. Was Informed consent taken before the
procedure
2. Was the procedure necessary in circumstances
3. Was it essential for saving life
4. Was the patient properly examined before
5. Was the patient fit to undergo both procedures

6. • PRE-SET QUESTIONS
6. Did the patient had any predisposing condition
7. Was the patient suitably prepared
8. Was suitable form of Anaesthesia administered
9. Were all anaesthetic instruments in proper working
10.Was there any mis-labelling of drugs or gases
11.Were both the procedures performed by qualified person
12.Was there any defect in procedure technique
13.Were suitable arrangements there in case of emergency
14.In Emergency were suitable protocols followed
15.Were suitable protocols followed for safe recovery
16.Would the patient have died without the procedure

7. • EXCLUSION & REASONING
Many anaesthetic deaths are physiological in nature which are
impossible to detect.
• Example
Cardiac arrythmias
Hypotension
Glottic spasm
Vagal Inhibition
Opinion in such cases should be using exclusion and reasoning.

8. PRELIMINARY INVESTIGATION
1. Visit to the Operation Room
Check for all the equipments
Check all valves and containers to ensure correct mixing of
gases with correct percentage was followed.
2. History
a) Any history of exposure to potentially toxic chemicals
before, during hospitalization or preanaesthesia
b) Obtain a list of such chemicals
c) Review of hospital charts
d) Discussion with hospital surgical & anaesthetic team

9. PRELIMINARY INVESTIGATION
3. EXISTING CONDITION
These include
a) High Risk Surgeries- for example resection of
aortic aneurysm
b) High Risk medical conditions-
Anemia, Hypertension,
Brown Atrophy of Heart
Interstitial pulmonary ds.
Myxedema, Thyrotoxicosis

10. PRELIMINARY INVESTIGATION
4. Anesthesia related factors
a) Preanesthetic Medications:-
i) Overdosage/ no medication
ii) Wrong drug given
b) Anesthetic agents:-
i) Information about anesthetic agent used
ii) Method of administration
iii) Inadverent wrong mixing of anesthetic agents
iv) Duration of time patient remained under anesthesia

11. PRELIMINARY INVESTIGATION
5. Equipment
i) all equipments including containers, valves etc working
properly
ii) mixing of gases ensued or not
6. Miscellaneous
i) Blood Transfusion Mismatch
ii) Burn or explosion during procedure
iii) Shock & Hemorrhages
7. Resuscitative measures taken

12. AUTOPSY
1. Examine all devices in situ
2. Open all cavities with devices in situ
3. Presence of any fluid in each cavity- preserve
4. Examine operation site
5. Artifactual findings
6. Surgical Errors
7. Odor – in case of inhalational anesthesia
8. Sutures- both external & internal

13. AUTOPSY
9. Viscera
10. Heart – send for histopathology
11. Brain- i) Hippocampal Gyrus & Cerebellum shows hypoxic changes
ii) Diffuse severe leukoencephalopathy of cerebral
hemispheres with sparing of immediate subcortical connecting fibers.
iii) Infarction of Basal Ganglia
iv) Damage is limited to White matter
12. Disease for which Operation was done

14. AUTOPSY
13. Common causes of DOT :-
DETECTABLE UNDETECTABLE
Asphyxia due to aspiration Cardiac arrhythmia
Embolism Hpotension
Anaphylaxis & Hypersensitivity Spasms(Coronary, Laryngeal)
Internal Hemmorhage Vagal Inhibition
Peritonitis
Retained Instruments, Swabs

15. AUTOPSY
• SAMPLES TO COLLECT
1) Blood
2) Pus or Exudate for culture
3) Histopathology – all organs
4) For Toxicology –
i) Viscera
both Lungs
other Viscera as for standard toxicology
ii) Alveolar air
iii) Gases from cavities, Heart ,Blood vessels
5) Extraneous Specimens- containers, solution, gases used
operating room air

16. LEGAL RESPONSIBILITIES
• Role during illegal procedures:-
i) Doctor should refuse to do such illegal procedures
Illegal MTP
Organ retrieval
Amputation of healthy limb for making beggars
ii) Bring to notice of legal authorities of all illegal activities
iii) If any illegal procedure is done with him part of team he is
party of crime and liable for legal action.

17. SUMMARY
• NO DEATH CERTIFICATE in cases of Death on Table.
• Cause of Death is usually difficult
• Full clinical history and consultation of team necessary to arrive at COD
• Where underlying pre-existing natural disease present contribution of this to cause
of death must be estimated.

18. DISCUSSION

19. THANK YOU
FOR PATIENCE LISTENING
Dr. Harendra Singh Bansal
Email:-
harendrabansal@hotmail.com