How to Read and Understand an Autopsy Report
Receiving an autopsy report can be an emotional and confusing experience. These documents are written in medical and scientific language that may be difficult for non-medical readers to understand. This guide walks you through the typical sections of an autopsy report, explains common terminology, and helps you know when to seek additional guidance from professionals.
Sections of a Typical Autopsy Report
While the format can vary by jurisdiction and provider, most autopsy reports contain the following sections:
1. Case Information
This section includes identifying details such as the decedent’s name, date of birth, date and time of death, date of autopsy, case number, and the name of the pathologist who performed the examination. It also lists the requesting authority (medical examiner, coroner, or family).
2. Circumstances of Death
A brief summary of the events surrounding the death as known to the pathologist. This typically includes information gathered from the scene investigation, medical records, witness statements, and law enforcement reports. This section provides context for the findings that follow.
3. Cause and Manner of Death
This is often the section families turn to first. It contains two critical determinations:
Cause of Death: The disease, injury, or condition that directly led to death. This is expressed as a chain of events. For example:
- Immediate cause: Pulmonary thromboembolism (blood clot in the lungs)
- Due to: Deep vein thrombosis (blood clot in the leg)
- Due to: Immobilization following hip fracture
- Due to: Fall from standing height
Manner of Death: A classification of the circumstances under which the cause of death occurred. There are five standard manners of death:
- Natural: Death resulting solely from disease or natural processes
- Accident: Death resulting from an unintentional injury
- Suicide: Death resulting from an intentional, self-inflicted act
- Homicide: Death resulting from the intentional act of another person (note: this is a medical determination, not a legal one — homicide in the medical context does not necessarily imply criminal intent)
- Undetermined: The pathologist cannot determine the manner of death based on available evidence
4. External Examination Findings
A detailed description of the body’s external appearance. This section documents physical characteristics (height, weight, body habitus), identifying features (scars, tattoos), evidence of medical treatment, and any injuries visible on the body’s surface. Measurements and locations of wounds are precisely documented.
5. Internal Examination Findings
An organ-by-organ description of the internal findings. Each major organ system is described, including its weight, appearance, and any abnormalities. This section uses medical terminology extensively and can be the most challenging for families to understand.
Common terms you may encounter include:
- Atherosclerosis: Hardening and narrowing of the arteries due to plaque buildup
- Cardiomegaly: Enlarged heart
- Hepatic steatosis: Fatty liver
- Pulmonary edema: Fluid accumulation in the lungs
- Contusion: A bruise
- Laceration: A tear in tissue
- Hemorrhage: Bleeding
- Necrosis: Tissue death
- Fibrosis: Scarring of tissue
- Effusion: Abnormal fluid collection in a body cavity
6. Microscopic Findings
Results from the examination of tissue samples under a microscope. This section describes cellular-level changes in each organ that was sampled. Microscopic findings often provide critical information about the progression of diseases, the age of injuries, and the effects of drugs or toxins on organ tissue.
7. Toxicology Results
A report of substances found in the decedent’s blood, urine, vitreous fluid, or other samples. Results are typically reported as concentrations (measured in milligrams per liter or nanograms per milliliter). The report may include:
- Blood alcohol concentration
- Prescription drug levels
- Illicit substance detection
- Over-the-counter medication levels
- Other substances (carbon monoxide, heavy metals, etc.)
Interpreting toxicology results requires specialized knowledge. The same drug concentration can be therapeutic in one person and lethal in another, depending on factors like tolerance, body weight, and interactions with other substances.
8. Opinion and Summary
The pathologist’s overall interpretation of all findings, synthesizing the physical examination, microscopic analysis, toxicology results, and case history into a coherent narrative of how and why the person died. This section provides the reasoning behind the cause and manner of death determinations.
Key Concepts to Understand
Cause vs. Manner of Death
These two terms are often confused but represent different things. The cause of death is the specific medical reason for death (e.g., gunshot wound, heart attack, drug overdose). The manner of death is the classification of circumstances (natural, accident, suicide, homicide, undetermined). A single cause of death could have different manners depending on the circumstances — for example, a drug overdose could be classified as accidental, suicidal, or homicidal.
Contributing Factors
The autopsy report may list conditions that contributed to death but were not the direct cause. For example, if a person with severe heart disease dies in a car accident, the heart disease might be listed as a contributing factor even though the traumatic injuries are the direct cause of death.
Pending and Deferred
If you see that the cause of death is listed as “pending” on a preliminary report, it means the pathologist is awaiting additional information (usually toxicology results or microscopic findings) before making a final determination. “Deferred” similarly indicates that a decision has been postponed until more information is available.
What to Do If You Have Questions
Contact the Pathologist
Most pathologists, whether government-employed or private practitioners, are willing to discuss their findings with the family. Contact the medical examiner’s office or the private provider and request a meeting or phone consultation. Many pathologists understand that families need explanations in non-medical language and will take the time to address your concerns.
Consult Your Own Physician
Your family doctor can help interpret medical terminology and explain what specific findings mean in the context of your loved one’s health history.
Seek a Second Opinion
If you have concerns about the accuracy or completeness of the autopsy findings, you have the right to seek a second opinion from an independent forensic pathologist. This pathologist can review the autopsy report, photographs, slides, and toxicology results to provide an independent assessment. A second opinion does not require a second physical examination of the body.
Consult an Attorney
If the autopsy findings suggest that the death may have been caused by negligence, malpractice, or criminal activity, an attorney experienced in wrongful death or personal injury cases can help you understand your legal options. Many attorneys who handle these types of cases have working relationships with forensic pathologists who can provide independent reviews.
Requesting Additional Testing
In some cases, families may want additional testing beyond what was included in the original autopsy. This might include more extensive toxicology panels, genetic testing, or specialized analysis. If you are considering additional testing, discuss this with the pathologist as soon as possible — some tests require samples that may have a limited preservation window.
Preserving the Report
Keep your copy of the autopsy report in a safe place. It is a legal medical document that may be needed for insurance claims, legal proceedings, obtaining death benefits, or family medical history purposes. If you lose your copy, you can typically request another from the medical examiner’s office or the private provider who performed the autopsy.