Introduction Competency-based medical education (CBME) emphasizes demonstrable competencies rather than time-based training. Miller's Pyramid remains an influential framework for conceptualizing clinical competence, but its contemporary application in forensic pathology education has not been comprehensively examined. This review evaluates its educational basis, applications, advantages, limitations, and relevance to forensic pathology teaching. Materials and Methods A narrative review was conducted of literature on Miller's Pyramid, CBME, workplace-based assessment (WPBA), entrustable professional activities (EPAs), milestones, programmatic assessment, and forensic pathology education. Educational and competency-based training approaches from India, the United States, Canada, and other settings were examined. Results Miller's Pyramid comprises four levels: Knows, Knows How, Shows How, and Does, representing progressive development from knowledge to independent practice. In forensic pathology, these levels can guide competency development in medico-legal autopsy, injury interpretation, evidence preservation, documentation, communication, and expert testimony. The framework facilitates alignment of learning objectives, teaching strategies, and assessment methods. However, its hierarchical structure may inadequately reflect the dynamic and context-dependent nature of competence and gives limited attention to professional identity, reflective practice, teamwork, and system-related influences. Integration with WPBA, EPAs, milestones, simulation, and programmatic assessment can address these limitations. Conclusion Miller's Pyramid remains a valuable framework for competency-based forensic pathology education. Its integration with contemporary assessment approaches can strengthen validity and support context-sensitive, longitudinal, and multimodal evaluation, ultimately promoting competent, accountable, and practice-ready forensic pathologists.
Introduction:In forensic science, confinement of the head within a plastic bag suffocation (PBS) combined with inhalation of volatile substances represents an uncommon but highly challenging scenario, particularly in determining the cause and manner of death. Materials and Methods:A retrospective analysis was conducted, including all 28,802 autopsies performed in Milan from 1993 to 2024. Twenty-eight cases of death due to PBS associated with inhalation of different gases (nitrogen, propane-butane mixtures, helium, propane, and butane) were identified. For each case, circumstantial data, autopsy findings, and toxicological and histological analyses were systematically reviewed. Results:Over a period of more than 30 years, this phenomenon predominantly involved young individuals from different social backgrounds and occurred in both suicidal and accidental contexts. In several cases, individuals appeared to use this method not only for suicide but also for recreational purposes, under the mistaken belief that gas inhalation could be controlled; however, rapid loss of consciousness often prevented any corrective action. Overall, 17 cases were classified as complex suicides, 5 as accidental deaths, and in 6 cases the manner of death remained undetermined. No cases were attributable to autoerotic practices or assisted suicide. Discussion:PBS combined with gas inhalation represents a multifactorial and highly lethal mechanism of death, often characterized by nonspecific autopsy findings and significant diagnostic challenges. Conclusions:These findings emphasize the critical importance of thorough scene investigation and contextual analysis, as removal of the plastic bag and the limited specificity of forensic findings may hinder accurate determination of the manner of death.
Introduction:Alveolar macrophages are key regulators of alveolar homeostasis and are highly sensitive to changes in oxygen availability. Experimental studies have demonstrated that hypoxic stress influences macrophage activation and accumulation within the lung. However, data on alveolar macrophage distribution in human autopsy material remain limited and heterogeneous. Materials and Methods:A retrospective histopathological study was conducted on autopsy lung tissue retrieved from the archives of the Institute of Legal Medicine of the University of Modena, Italy. Cases of asphyxial death due to neck compression (hanging, ligature strangulation, and manual strangulation) were compared with nonasphyxial control deaths due to isolated traumatic brain injury. Routine hematoxylin and eosin-stained sections were analyzed. Alveolar macrophages were counted in five nonoverlapping high-power fields per case, and the mean macrophage count per field was used for statistical analysis. Results:A total of 145 cases were included, comprising 51 asphyxial deaths and 94 control cases. Asphyxial deaths showed significantly higher alveolar macrophage counts compared with controls (median 5.4 vs 2.0 macrophages per high-power field; p < .001). Exploratory receiver operating characteristic analysis yielded an area under the curve of approximately 0.87, suggesting a moderate to good discriminatory performance. Discussion:Asphyxial deaths due to neck compression are associated with increased alveolar macrophage counts in routine autopsy lung tissue. These findings support a role for alveolar macrophages in the pulmonary response to acute hypoxic stress. Conclusion:Alveolar macrophage quantification may represent a supportive histopathological feature of asphyxia, although it should be interpreted within a broader multiparametric framework.
Introduction:Cocaine is a powerful stimulant with significant potential for fatal intoxication. Distinguishing between accidental and intentional cocaine overdoses requires careful integration of toxicological, situational, and behavioral evidence. Materials and Methods:A postmortem toxicological analysis was performed on peripheral blood samples using gas chromatography-mass spectrometry and headspace gas chromatography with flame ionization detection to quantify cocaine, its metabolites, and ethanol. Results:The analysis revealed high concentrations of cocaine (1.602 mg/L), benzoylecgonine (89.173 mg/L), cocaethylene (12.417 mg/L), and ethanol (0.61 g/L). The decedent was a 29-year-old man with a history of substance abuse, discovered deceased in a hotel room. The cause of death was identified as cardiogenic shock due to acute cocaine intoxication. Discussion:The toxicological profile suggests nonrecreational use, possibly with suicidal intent, given the extremely elevated drug levels and circumstances of death. These findings underscore the importance of integrating analytical data with situational and behavioral context to distinguish between accidental and intentional drug-related deaths. Conclusion:A review of existing literature indicates that the vast majority of lethal cocaine ingestions are accidental; consequently, this represents a rare, documented case of cocaine overdose involving possible suicidal intent. This case highlights the need for comprehensive evaluation, combining toxicological findings with contextual information, when determining the manner of death.
Range of fire determination in shooting fatalities classically depends on the gross presence, distribution, and density of visible gunshot residue (GSR), including soot, stippling, and bullet wipe surrounding the entrance wound. Scalp hair has been suggested to interfere with GSR deposition in head wounds, but few experimental studies have systematically addressed this variable. Misinterpretation of GSR findings in hair-covered wounds carries significant medicolegal consequences. In this study, controlled discharge testing was performed using a Ransom International Forensic Ballistic Machine. Three cosmetology-grade mannequin heads with synthetic vinyl skin and 100% human hair were used: short, tightly curled (max 6 inches); long, straight (max 22 inches); and medium, straight (max 12 inches). Five firearms (.22 Long Rifle, .40 S&W, 9 mm Parabellum, .45 Auto, .223 Remington) were discharged at 2 inches and 6 inches into five scalp regions (left temporal, left parietal-occipital, occipital, right parietal-occipital, right temporal), producing 50 defects. Visible GSR was assessed before and after shaving. Visible GSR was present in 19 of 25 defects (76%) at 2 inches and nine of 25 (36%) at 6 inches. Within tightly curled hair, GSR was visible in only seven of 20 defects (35%). All .22 Long Rifle defects showed visible GSR (10 of 10). Results reveal that dense, tightly curled scalp hair can substantially reduce or eliminate visible GSR even at short range. Absence of visible GSR in hair-covered defects should not, alone, be interpreted as evidence of distant or indeterminate range of fire.
Forensic dental examination was performed on a nearly skeletonized decedent in whom both maxillary and mandibular complete dentures remained, an uncommon finding in deceased individuals. Careful manipulation of residual soft tissues permitted visualization of the underlying osseous and prosthetic components. Postmortem findings demonstrated extensive implant therapy in both arches, consisting of implant-supported fixed complete dentures retained by multiple endosseous implants. Antemortem dental records, including digital panoramic and periapical radiographs with treatment documentation, were reviewed for comparison. A discrepancy in the number of maxillary implants between antemortem and postmortem findings was identified and resolved through review of treatment notes, which documented a single implant failed and was removed prior to denture placement. Differences in implant numbering were due to listing the implants postmortem based on denture tooth positions rather than the originally replaced teeth. Additionally, a single antemortem periapical radiograph, initially considered of limited clinical significance, contributed to identification by demonstrating residual root structure following extraction. This case emphasizes the forensic importance of comprehensive evaluation of all available dental records and imaging.
Background:Drowning remains a diagnosis of exclusion in forensic pathology due to a lack of sensitivity and specificity in currently identified drowning signs. This study aimed to assess the diagnostic value of combined lung weight (LW) and lung-to-body ratio (LBR = LW/body weight × 1000) in differentiating drowning deaths from nondrowning deaths. Methods:A retrospective case-control study was conducted using autopsy records from the Peoria County Coroner's Office (2011-2025), including 96 freshwater drowning cases and 99 age- and sex-matched nondrowning controls. Deidentified variables analyzed included LW, LBR, age, sex, body weight, degree of decomposition, and cardiopulmonary resuscitation (CPR) status and toxicology results (the presence or absence of drugs). Statistical analyses compared variables between cases and controls and evaluated the effects of covariates on LW and LBR within groups. Results:Both LW and LBR were significantly higher in drowning cases than in controls (p < 0.001). Subgroup analyses demonstrated that LBR was influenced by age but not by sex, CPR status, decomposition category, or the presence of drugs (within cases). LW, on the other hand, was affected by sex and age in controls, and by decomposition category, CPR status, and drug presence in drowning cases. Conclusions:While both LW and LBR appear to be significantly elevated in drowning deaths, LBR may serve as a more reliable metric than LW when assessing the likelihood of drowning, as it is less affected by confounding factors.
Background:Coronary artery anomalies (CAAs) represent one of the most complex pathologies in cardiology. Right coronary artery anomaly (RCA) is extremely rare. Often this condition is asymptomatic and diagnosed accidentally; however, in some cases it can have a catastrophic onset and cause sudden death. Case Report:We present here a rare case of sudden cardiac death (SCD) of a 27-year-old man due to a RCA with origin from the left coronary sinus and abnormal course, exacerbated by the Valsalva manoeuvre during defaecation. Conclusion:We emphasise the need for a careful and comprehensive approach in cases of SCD. In these cases, a careful and thorough analysis of the origin and course of the coronary arteries is necessary.
We present a photograph, taken at autopsy, of a very unusual, well-defined and preserved, patterned mark on the internal aspect of a subject's trousers, caused by the tyre of a large agricultural vehicle in a fatal run-over road traffic accident. The mark was formed by superficial skin components that had been forced onto the overlying internal surface of the denim jeans, during the incident and considered to be sufficiently detailed for potential forensic comparison work. Establishing the likely dynamics of a fatal road traffic incident and identifying/collecting trace and other evidence, that may help identify the vehicle involved in cases of uncertainty, forms a key part of the post mortem examination. This requires the pathologist undertaking the autopsy, not only to perform a detailed examination of the body of the deceased, but also to inspect the clothing. This case highlights the need to also carefully look at the inside surface of the clothing material.
Late-onset vitamin K deficiency bleeding (VKDB) remains a preventable cause of catastrophic intracranial hemorrhage in early infancy, yet continues to present complex medicolegal challenges where parental refusal of prophylactic vitamin K persists. We present four infant deaths evaluated within the Turkish medico-legal system, each lacking prophylactic vitamin K at birth, in which autopsy played a critical role in excluding alternative causes and supporting findings most consistent with VKDB. Comprehensive review of clinical records and full forensic autopsies, including neuropathologic examination, demonstrated extensive multi-compartment intracranial hemorrhage with no findings sufficient to support inflicted trauma, skull fractures, vascular malformations, metabolic disease, congenital coagulopathy, or sepsis. Coagulation studies, when available, showed markedly prolonged prothrombin time/international normalized ratio and activated partial thromboplastin time, supporting acquired coagulopathy consistent with vitamin K deficiency. In all cases, postmortem findings aligned with clinical deterioration characterized by rapidly progressive neurologic decline. The circumstances surrounding refusal of prophylaxis, delayed medical presentation, and progression to fatal hemorrhage were evaluated in the context of medicolegal responsibilities regarding caregiver decision-making and cause-of-death certification. These cases underscore the critical role of forensic pathology in differentiating VKDB from non-accidental trauma and other causes of infant intracranial hemorrhage, ensuring accurate death investigation, and informing medicolegal evaluation in preventable infant deaths.
Paternal filicide is the deliberate killing of one's child by the father. It is a rare form of homicide that is complex and disturbing, as it might involve child domestic violence in its course. It reflects on the underlying psychodynamic and socio-economic stressors. We report a case of a paternal filicide by smothering involving a 4-year-old male child, associated with chronic child abuse. Autopsy examination revealed bluish discolouration of the nail beds, multiple abrasions and contusions present over the bilateral cheeks, nose, lips, submandibular region, right lateral aspect of the body, front and back of the body, indicative of physical abuse. Internally, blood in the peritoneal cavity was present. Multiple petechial haemorrhages are present over the heart and lungs. A haemorrhagic area was present over the mesentery. Death was due to asphyxia, consistent with smothering, in a background of multiple blunt force injuries suggestive of chronic child abuse. This case highlights the intricacies in determining the cause and manner of death in filicide cases that were associated with child abuse based on the chronology and mechanism of fatal injuries.
Aims:Suicide by hanging remains a common modality of death across the globe. Despite this, the reported incidence of laryngohyoid fractures in suicidal suspensions remains widely varied across the current literature. This audit was conducted to benefit from a single institution's standard method of practice, coupled with a sufficiently large enough data set, to draw better conclusions on the incidence of laryngohyoid fractures in such cases and any predicting variables. Method:Autopsy records for a total of 12 years from January 2011 to May 2023 were examined to identify cases of suicidal hanging and determine the laryngohyoid fracture incidence. A range of subsequent data relating to the deceased, the ligature, the suspension and post-mortem findings were recorded and statistically analysed to identify significant variables associated with the presence of such fractures. Results:A total of 383 autopsy reports were included. Overall incidence of any laryngohyoid fracture was 59.3%. Thyroid and hyoid fractures were found in 51.4% and 29.2% of these cases, respectively. The most common fracture pattern was fractures of the bilateral superior thyroid horns. Significant associations between fracture incidence and the following variables were identified: ligature type, ligature mark, petechiae, age and height. Conclusion:This audit highlights the ligature as a potential important predictor in the presence of laryngohyoid fracture. There is a relative paucity of information relating to the ligature used and the incidence of fracture. Future efforts should be focused on prospective and standardised collection of data, with particular focus on the ligature type.
Background:Tension pneumothorax is a life-threatening condition in trauma patients requiring rapid recognition and treatment. Needle thoracostomy (NT) is a critical prehospital intervention to treat this condition. Objective:To evaluate prehospital NT performance through medical examiner (ME) assessment of anatomical placement, pleural space access, and complications in prehospital nontransported traumatic cardiac arrest patients. Methods:A prospective observational study reviewed 144 prehospital NTs performed on 77 patients after initial emergency medical service (EMS) care from 01 February, 2022 to 16 June, 2024. NTs were evaluated during autopsy for placement within recommended external anatomical landmarks, pleural space entry, and evidence of complications. EMS documentation was reviewed to correlate findings. Results:Of 124 lateral chest wall NTs, 35.5% were outside of recommended anatomic landmarks and 34.6% did not access the pleural space, with a 14.5% complication rate. Among 20 anterior chest wall NTs, 10% had incorrect external placement and 80.0% did not access the pleural space, with a 5.0% complication rate. When comparing lateral chest wall NTs to anterior chest wall NTs the difference in correct external placement (P = .036) and pleural access (P < .001) were statistically significant but the complication rates (P = .474) were not. Conclusion:Autopsy-based review provides valuable insight into the real-world performance of prehospital NTs. Lateral chest wall NTs have high rates of incorrect external anatomic placement but more often access the pleural space as compared to anterior chest wall NTs. Complications are rare overall. This collaborative model between the ME and EMS can identify trends and challenges, inform training, guideline development and system-level improvements.
Modern medical education increasingly emphasizes deep learning, professional identity formation (PIF), and longitudinal competency development. The tea-steeping metaphor, drawn from the gradual infusion process of tea leaves into water, offers a novel lens to conceptualize immersive and time-dependent learning. This metaphor holds particular relevance in forensic medicine, where learners must develop a nuanced understanding of medico-legal principles, ethical reasoning, and procedural competence over time. Objective of this article is to explore the origin, educational applications, benefits, limitations, and practical impact of the tea-steeping metaphor in the context of forensic medicine teaching. A narrative review methodology was employed, integrating theoretical frameworks from constructivist learning, competency-based education, and experiential learning. Real-world applications in forensic education were examined, including longitudinal case-based learning, simulation-based training, reflective practice, and PIF. The tea-steeping metaphor supports gradual cognitive and affective skill development by allowing learners to process complex information over time and within context. In forensic medicine, this approach enhances critical thinking, ethical decision-making, and integration of theory with practice. Benefits include promotion of deep learning, reflective practice, and adaptability. However, challenges such as time constraints, potential information overload, and the need for optimal learning conditions limit its universal applicability. The tea-steeping metaphor provides a valuable pedagogical framework for forensic medicine education. When implemented strategically, it can foster immersive, reflective, and ethically grounded learning experiences. Further research is warranted to assess its longitudinal outcomes and adaptability across diverse educational contexts.
COVID-19 related "quorum deaths" may conceal fatal angioedema/anaphylaxis that is misclassified as primary respiratory failure or cardiac arrest, particularly when urticaria or an identifiable allergen is absent. We propose an expanded diagnostic and forensic framework in which SARS-CoV-2-associated endothelial injury converges with mast cell activation disorders and complement system maladaptation, producing a self-amplifying mast cell-endothelium-complement axis capable of terminal vascular collapse without prominent systemic inflammation. To reduce diagnostic indeterminacy and improve cause-of-death attribution, we outline pragmatic postmortem approaches: early serum tryptase sampling, complement studies (C4 and C1-inhibitor levels), targeted histology for perivascular mast cell degranulation in the larynx and terminal pulmonary bronchioles, and selected genetic testing for hereditary angioedema and mast-cell-related variants (e.g., SERPING1, KIT D816V). Integrating these investigations into forensic workflows may reduce misclassification, strengthen pharmacovigilance, and support pandemic-era risk stratification and equity.
Machinery, whether it is operating or idle, may cause various types of contact injuries, including caught-in or caught-between incidents with moving parts, avulsions, amputations, burns, crush injuries, falls, and impacts with the machine or surrounding surfaces. Despite the prevalence of industrial accidents, fatalities caused by chemical blender machines have never been reported. This case reports a rare fatal case involving a 48-year-old male who sustained musculoskeletal injuries after falling into a chemical blender mixer while manually stirring powder in an industrial setting. The victim became trapped in the machine for ∼30 s, leading to extensive lacerations and fractures, and died due to hemorrhagic shock. The autopsy revealed multiple lacerations and fractures on the lower limbs due to the machine's helical blades, alongside a deep laceration on the right shoulder. Internal injuries included rib fractures, liver lacerations, and significant blood loss, ultimately causing death. The unique design of the blender machine blades, with helical-shaped blades, played a critical role in the injury pattern. A crime scene investigation emphasized the absence of proper safety measures, such as guarding mechanisms, which allowed the victim's entrapment.
