There have been many recent media reports pertaining to the strike action by forensic officers at medico-legal mortuaries in Gauteng. It is clear from most of these reports that there is a severe lack of knowledge regarding the practice of forensic death investigations.
In particular, there also appears to be a very poor understanding pertaining to the scope and nature of medico-legal autopsies and specifically, the roles and functions of the medical practitioners responsible for such autopsies – and those of their assistants. Pathologists are specialist medical doctors who have undergone further postgraduate training after completing their medical degree. Forensic pathologists have specifically specialised in the field of pathology which deals primarily with the pathology of traumatic injury, poisonings and other non-natural causes of death. It takes a minimum of thirteen years of undergraduate training, vocational experience and postgraduate study, with multiple intensive examinations, before one can qualify as a forensic pathologist.
The doctor can then register with the Health Professions Council of SA (HPCSA) as a specialist forensic pathologist. Thus it is grossly inaccurate to refer to forensic officers and those who function as assistants to forensic pathologists, as being forensic pathologists – as has been repeatedly done by ill-informed reporters, union representatives and even government officials recently.
For centuries, both internationally and locally, doctors/pathologists have conducted autopsies with the help of assistants who are not medically qualified. The role of such assistants is to aid with preparing the body, positioning and presenting it for the pathologist, to assist with specified dissection procedures, to eviscerate organs and to clean body cavities, return tissues to the body and to reconstitute the body, by sewing up thereof, washing the body and making it available to undertakers – who will then further prepare the body for burial or cremation. Such assistants (who are not doctors) who work with bodies and do certain dissection procedures are not unique to the field of forensic pathology, but are also found in anatomy departments at medical schools, at undertakers premises and funeral parlours (where private autopsies are performed in preparation for cremations or where organs are removed for example, for referral to specialist medical centres for subsequent examination with a view to establishing whether the deceased’s family qualify for compensation for occupational diseases).
When a radiographer (for example) prepares x-ray plates of a patient or performs a CT-scan, he/she does not claim to be a radiologist (a specialist medical practitioner); when a nurse inserts a catheter for a patient or administers an injection, that does not make him/her a doctor. When a scrub nurse or sister assists a surgeon in performing an operation, that does not make of her a surgeon and she cannot claim to have “performed the operation”. None of these functions detract from the duties and relative value of the service provided by the assistant – but they do not warrant the person in question being promoted to a medical specialist or doctor.
There are numerous other examples of medical professionals who require the assistance of persons who are not medically or otherwise qualified, but who work with human tissue: such persons are found also in university departments of anatomical pathology, police forensic laboratories, human tissue laboratories, funeral undertakers (where they are also responsible for embalming bodies and cosmetic reconstitution of traumatised or decomposed bodies, etc.). Performing these auxiliary functions does not make of them doctors, transplant surgeons or pathologists.
In much the same way, it is a reductionist and simplistic representation to contend that the mere cutting open of or removal of tissues or organs from a body, constitutes the “conducting of a post mortem examination”. To conduct a post mortem examination means that due regard is had, for the full medical history and circumstance of death, to plan and strategize regarding the scope and nature of the examination required for that particular case, taking into account the relevant occupational health perspectives and risks (for example specific contagious disease which may be present), the need for specialised dissection procedures according to the nature of the pathology which is expected and ensuring that the correct evidentiary and diagnostic specimens are collected for further microscopic, toxicologic and other examinations. Above all, the pathologist must inspect and examine organs and tissues and – having due regard for a myriad of pathological conditions and injury manifestations – must record and interpret these findings, ultimately integrating the sum total of findings ranging from medical history, macroscopic autopsy manifestations, specialist laboratory and toxicology findings, microscopic examinations and more, before arriving at a diagnosis or conclusion.
South African forensic pathologists are recognised internationally for having been well trained and being highly competent – and many of these locally trained pathologists now occupy posts as senior pathologists or heads of medical examiner or coroner offices in Canada, the USA, Australia and the UK, to name but a few. South Africa has a massive annual burden of non-natural deaths which require forensic medical examination – having arguably the highest non-natural death rate in the world (at least for countries not at war or beset by famine).
There are only approximately fifty to sixty qualified specialist forensic pathologists in South Africa. However, there are several hundred other qualified medical practitioners with postgraduate training and diplomas in forensic pathology, which do not make them specialist pathologists but equip them and make them valuable professionals responsible for conducting medico-legal autopsies. These specialist forensic pathologists and other medical practitioners are responsible for conducting the approximately 70 000 – 80 000 medico-legal autopsies which have to be performed annually in South Africa. It is to be expected that these medical practitioners will require the support of assistants in the capacity which has previously been described. Despite the fact that these assistants contribute to the medico-legal investigation, it should be stressed that the doctor / pathologist at all times is responsible for the overall and direct control of the autopsy process, with direct supervision and instructions to assistants, from beginning to end. The pathologist must observe all anatomical or tissue pathology, injuries and other relevant findings, and must ensure that these findings are recorded, that appropriate specimens are collected, preserved, packaged and dispatched and ultimately must prepare a technical medical report which will serve the judicial process and withstand scrutiny in a court of law, where thorough questioning by legal counsel is encountered (often also assisted by other medical experts).
It is absurd to suggest that the non-medically trained assistants at such autopsies have been responsible for “conducting the autopsies” or that they would be capable of orchestrating the totality of such a required examination, and of compiling the technical medical reports required for subsequent legal processes. In conducting such medico-legal autopsies, it is of course inevitable that the pathologist / doctor will need to rely on the support and input of forensic officers as assistants, and it is recognised that all parties contribute to the eventual proper investigative process. Pathologists must also trust the contribution and input of forensic officers: for example, upon admission to medico-legal mortuaries, the bodies of decedents are recorded at a built-in weighing station and body length measured, before later (usually the following day) being presented to the doctor / pathologist with these recorded measurements. The doctor / pathologist must rely upon these independently observed and recorded observations of the forensic officer / assistant, although clearly at all times retains the responsibility and discretion to query inappropriate measurements in respect of mass, body length, etc. Similarly, forensic officers assist with for example, the radiographic scanning of bodies in those facilities which have such equipment, by positioning the body and assisting in the operation of the radiographic apparatus. It remains the responsibility of the attending medical practitioner / pathologist to subsequently review the radiographic images in order to assess and diagnose possible pathological or other features.
The results and findings provided by doctors / pathologists in their post mortem reports are always subject to review and scrutiny by the judicial process and in the courts. As in any other discipline or profession, inexperience and inadequate training may compromise the quality of reports generated by doctors, but this does not mean that there is a need for full scale review of reports which have been submitted to the courts. The suggestion that numerous post mortem examination reports are grossly inaccurate because the autopsy was in fact “conducted” by the doctor’s assistant, is to say the least, misleading and incorrect.
Every person who has applied for a position as a forensic officer (assistant) within the respective provincial departments of health knew full well and in advance what the scope and nature of their expected duties would be: in particular, they knew that they would be expected to assist with dissection and evisceration duties – this has been standard practice for decades. No person applies for a job which entails working with and dissecting dead bodies and is unaware of the nature of the duties which will be expected of them! Forensic officers who assist at autopsies receive initial and ongoing vocational in-house training by pathologists and senior colleagues in order to better equip them to perform these services. It is indeed so that there is currently no structured postgraduate or tertiary academic course for forensic officers or dissection assistants – although a registered SAQA qualification has been developed and advised by pathologists.
Prior to 2006 the medico-legal laboratories were administered by the South African Police Service (SAPS) and all dissection assistants were SAPS officers – an arrangement and service which was thus rendered for probably more than a hundred years. None of these SAPS officers were formally medically trained in any way, other than being supervised and given in-house vocational training and guidance by the medical practitioners with whom they worked.
When the mortuaries were transferred from the SAPS to the Department of Health in 2006, many of these SAPS officers chose not to transfer to the Department of Health, but to remain within the police service. It was thus necessary for the Department of Health to employ many new forensic officers, a substantial number of which at that time had no prior specific experience of working in mortuaries. As such, it is possible that some of these forensic officers had previously worked as drivers or as assistants at funeral parlours, etc. However, only those who were appointed as forensic officers were called upon to specifically assist pathologists or doctors with the autopsy and/or dissection procedures.
After the transfer of mortuaries to the department of Health, a tertiary level SAQA registered qualification was indeed developed in 2007, to better equip and qualify forensic officers to assist and contribute to the full range of services required in the medico-legal investigation of death, beyond just the support functions at the autopsy: these would include the appropriate protocols required in investigating bodies at death / crime scenes, proper transportation to the mortuary, identification procedures pertaining to the bodies (for example, the taking of fingerprints), improved awareness of occupational health issues, to name but some. It is unfortunate that no tertiary level academic institutions in the country have found it to be a viable qualification, probably because of the expected relatively low intake of such student numbers. It would indeed be preferable or feasible for the Department of Health to employ persons who have relevant higher qualifications (such as bachelors’ degrees in biomedical sciences and/or anatomy) to render these services – if the available monetary resources would allow for that. Clearly, the cost of employing such persons with higher educational qualifications and skills would substantially impact upon the budget requirements for the forensic pathology service. Unfortunately, resource constraints in South Africa and competing needs for other health care services – such as management of infectious diseases, mother and child care, vaccination services, etc. – compete directly with fiscal allocations in this regard. In adequately resourced countries like the USA, Canada and the UK, it is possible to employ only qualified graduates to render these services – but this is probably not feasible in SA at this time.
Over the past decade or more, the Forensic Pathology Service (FPS) in South Africa has been dramatically improved upon with multiple new mortuaries having been built, some of which are state of the art facilities of an international standard (such as the facility in Bloemfontein and the new facility under construction in Cape Town). In addition, the budget allocation for forensic pathology services has been more than quadrupled, with more staff, vehicles, equipment and general infrastructure. This includes the installation of highly sophisticated radiological equipment at a number of mortuaries, such as the multi-million rand Lodox Statscan apparatus. Dedicated and custom made vehicles are now used to transport bodies and FPS staff are now professionally attired and equipped – at scenes and in the mortuaries and are being issued with protective equipment. Budget constraints and supply logistics problems beset the FPS as it does most other state departments, but overall there has been a significant improvement in the level of the service rendered since the take-over by the health department. There are still many aspects which require upgrades and improvements in this service, not least of which are the training and service conditions of forensic officers / assistants, better training of doctors, and diagnostic services such as toxicology, etc.
Forensic pathologists and forensic officers certainly work under adverse conditions and undeniably, in a resource constrained environment. The work they perform is often not of a pleasant nature and due recognition should be given to the fact that they are exposed to physical dangers, psychological trauma and the stressful environment of working with emotionally traumatised and bereaved families.
All efforts to improve on the physical environment and vocational skills required for the rendering of a legally prescribed medico-legal investigation of death service, must be welcomed and proactively sought by all parties concerned. But in presenting the case for better resource allocation and improved working conditions, it is essential that there is accountability and objectivity – and for responsible reporting and dissemination of accurate information by the media and officials. Irresponsible statements and media reports – the likes of which we have seen lately – will undoubtedly discourage other medical professionals to enter this field of service and will furthermore de-motivate the few existing specialists and trainee specialist, or encourage them to seek other pastures, as many of their colleagues have done.
Author: Professor Gert Saayman