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Much that is constructive can be achieved from analysis of death investigations that have failed to achieve desirable outcomes in terms of learning lessons about risks to health and safety and in terms of gaining an understanding as to how further tragedies can be avoided. This article reviews an "inquest" into the sinking in 1628 of the pride of the Swedish Navy, the Vasa, and the factors that led to the inquest failing to come to grips with the various design, building, oversight, subcontracting, communication, and co-ordination flaws that contributed to the vessel being foreseeably unstable and thus unseaworthy. It argues that Reason's Swiss cheese analysis of systemic contributions to risk and modern principles of Anglo-Australasian-Canadian death investigation shed light on how a better investigation of the tragedy that cost 30 lives and a disastrous loss of a vessel of unparalleled cost to the Kingdom of Sweden could have led to more useful insights into the multifactorial causes of the sinking of the Vasa than were yielded by the inquest., Competing Interests: None.

This review analyses historical sources on the development of forensic medicine and the coroner system in the town of Bjelovar over the past two centuries. The development of these two professional fields in the context of public health was regulated through a number of bylaws, such as Normativum Sanitatum from the time of the Habsburg Monarchy. Coroner examinations were performed by physicians, surgeons, and laymen using special instructions such as the famous booklet by nobleman and county medical officer Vilim Peičić from 1914. Forensic autopsy was performed by surgeons, primary or secondary hospital physicians in case of sudden or suspicious in-hospital deaths, whereas outpatient forensic autopsies were performed by county or town medical officers and district physicians at the request of investigating authorities (police, court, or general attorney's office). This historical review should serve as the basis for further historical research into this field in Croatia so as to obtain deeper insight into the development of forensic medicine and the coroner system, two professions that have always been a vital factor in public health.

Thomas Wakley--founding editor of The Lancet, member of Parliament, coroner and, for 12 years, all three simultaneously--died 150 years ago. His fullest biography is more than a century old, but still provides a good account of the struggles and achievements of this extraordinary yet at times rather difficult and overstretched man. Nonetheless, there are gaps, and this anniversary provides a chance to fill in a few of them., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Internal autopsies are invasive and result in the mutilation of the deceased person's body. They are expensive and pose occupational health and safety risks. Accordingly, they should only be done for good cause. However, until recently, "full" internal autopsies have usually been undertaken in most coroners' cases. There is a growing trend against this practice but it is meeting resistance from some pathologists who argue that any decision as to the extent of the autopsy should rest with them. This article examines the origins of the coronial system to place in context the current approach to a death investigation and to review the debate about the role of an internal autopsy in the coronial system.

On 1 March 1886, a new morgue built along the lines of the Paris morgue, was opened in Berlin, Germany. Experts from many European countries were interested in the new building with its modern design and equipment. As the morgue, the Institute of Legal Medicine of the Berlin University accommodated in the same building also acquired international reputation. However, neither the scientific nor the economic achievements of this long-standing institution could prevent the closure of this historic site in Berlin-Mitte after almost 125 years.

There have been wide-ranging debates about medicine and the law encapsulated in the figure of the coroner in Victorian England. Recently the historical literature on coroners has been enriched by macro-studies. Despite this important research, the social lives of coroners and their daily interactions remain relatively neglected in standard historical accounts. This article redresses that issue by examining the working life of the coroner for Oxford during the late-Victorian era. Edward Law Hussey kept very detailed records of his time in office as coroner. New research material makes it feasible to trace his professional background, from doctor of the sick poor, to hospital house surgeon and then busy coroner. His career trajectory, personal interactions, and professional disputes, provide an important historical prism illuminating contemporary debates that occupied coroners in their working lives. Hussey tried to improve his medico-legal reach and the public image of his coroner's office by reducing infanticide rates, converting a public mortuary, and acquiring a proper coroner's court. His campaigns had limited success because the social scene in which he worked was complicated by the dominance of health and welfare agencies that resented his role as an expanding arm of the Victorian information state.

The autopsy technique evolves with extending knowledge and technical and technological progress in medical sciences. The objective of this report is to present the main autopsy techniques and an outline of transformations that occurred in the methodology of post mortem examinations with a focus on the Polish literature. Additionally, we present examples of paintings inspired by autopsy.

This article analyzes infanticide based on the Coroners' Records for Providence County, Rhode Island, from the 1870s to 1938 to determine doctors' and coroners' attitudes toward mothers who killed. The nineteenth century witnessed a medical discourse on the possibility of postpartum insanity as a cause of infanticide. While some women claimed temporary insanity, and some doctors and coroners legitimated this defense, its application to mothers who killed was arbitrary. They determined who deserved this diagnosis based on the woman's character, her forthrightness, and extenuating circumstances. Infanticide divided the profession nationally and at the local level and prevented doctors or coroners from speaking in a united voice on the issue. This article does not attempt to follow cases of infanticide through to jury verdicts. Instead, it provides an opportunity to analyze the circumstances women faced that led them to kill their newborns, and to analyze the responses of doctors and coroners to these mothers who killed. Unlike the findings of other studies, neither physicians nor coroners in Rhode Island were united in a claim of ignorance to save these women from guilty verdicts.

The first general surgical operation performed on an etherised patient in New Zealand took place early on the afternoon of Monday, 27 September 1847, at the recently opened Wellington Colonial Hospital. The surgeon Dr JP Fitzgerald, M.D. was assisted by Dr GD Monteith and the ether was administered by JH Marriott Esq. Whereas the biographies of Dr Fitzgerald and James Manrriott have been well documented nationally, little has been recorded concerning Dr Monteith. The following article has been compiled in an attempt to prevent the life and contributions of Dr Monteith from slipping into oblivion.

This article examines the application of the Anatomy Act (1832) at Oxford University, circa 1885-1929. For the first time it retraces the economy of supply in dead bodies, sold by various black-market intermediaries and welfare agencies, transported on the railway to Oxford. Both pauper cadavers and body parts were used to train doctors in human anatomy at a time when student demand always exceeded the economy of supply. An added problem was that the trade in dead bodies was disrupted by a city coroner for Oxford in a bid to improve his professional standing. Disputes about medico-legal authority over the pauper corpse meant that the Anatomy Department failed to convince the local poor in the city center to sell their loved ones' remains for dissection on a regular basis. Adverse publicity was a constant financial headache for anatomists. Consistently, they had to pay higher prices for cadavers than their competitors did. Often bodies were purchased in surrounding Midlands towns. This context explains why the Anatomy Department at Oxford failed at the business of anatomy in the late Victorian and early Edwardian eras.

The coroner's office, created in England in 1194 to hold inquiries into suspicious or violent deaths, was established in Quebec and Montreal in 1764. From 1765 to 1930, more than 16,000 reports, housed in the provincial National Library and Archives, were documented for the district of Quebec. A database was created to facilitate access for those interested in past customs, in provision of medical care, in attitudes towards death, in crime, in the effects of industrialization, and in new ways of production. This paper summarizes the most important elements of this database, gives a chronological account of the office of the coroner, describes the documents, and show the connection between the inquiries of the coroners and the socioeconomic events of the region.

Anaesthetists are acutely aware of the legal constraint of reporting to the coroner deaths in association with anaesthesia. The evolution of the office of the coroner in England is presented and the relationship with the discovery and evolution of anaesthesia is examined. The legal and medical climate in the 19th century is described, with some of the key participants named and their roles explained. The 19th century was an age of questioning and exploration, which led to the elucidation of the problems with chloroform and set the path for progress in monitoring in anaesthesia. Comments are made on the development of anaesthetic mortality reporting into its current system and some of the benefits flowing from it. The collaboration of the various state mortality committees in producing a triennial national report is an important way to ensure that the lessons of the past are kept in mind in the present. The author believes that mortality reporting, the analysis of data and the dissemination of information is a valuable field of research, monitoring and educational tool. Primum non nocere is particularly pertinent in anaesthesia.

The author briefly presented development of forensic medicine as a separate branch of medical sciences in Poland from the end of the Middle Ages to date. He comments on conditions in which forensic medicine developed after partitions of Poland and its restoration of independence. He emphasized the merits of Prof. Wachholz and his pupils, as well as the great publishing effort of forensic scientists during the interwar period and after World War II. He did not fail to highlight links between Polish and German forensic medicine and quotes numerous examples of very close contacts between both communities in this field.

The evolution of medical jurisprudence in ancient China is discussed in relation to Sung Tz'u (1186-1249), a district judge in the Southern Sung Dynasty. His work represents some of the earliest on the subject.

Part 1 of this series began in 1194, when the coroner system was formally established in England with the original interest in death to protect the financial interest of the crown. This coroner system was brought to the United States during the early 1600s where the first recorded autopsy was performed in Massachusetts in 1647. Significant changes were made to improve upon the coroner system. In 1877, the first medical examiner system was established in the state of Massachusetts, requiring that the coroner be supplanted by a physician known as a medical examiner. Using the system established in Massachusetts as a model, New York City developed an improved medical examiner system in 1915. The improvements made by New York City, under the leadership of men such as Drs. Charles Norris and Alex Gettler, essentially laid down the foundation for medical examiner systems and forensic toxicology throughout the country. Part 2 of this series begins in Maryland. Maryland soon followed in New York City's footsteps and in 1939 developed the first statewide medical examiner system in the U.S. Influenced by systems such as Maryland's and New York City's, Delaware established a medical examiner system in 1955 to work alongside of the pre-existing coroner system. It was not until about a decade later, in 1964, that the system became successful under the leadership of Dr. Ali Z. Hameli. In 1970, after 15 years of uphill battles with supporters of the antiquated coroner system, it was abolished, resulting in a statewide medical examiner system. Today, Delaware's medical examiner system has one of the best medicolegal investigative facilities in the country, complete with its own forensic sciences laboratory under the jurisdiction of a Chief Medical Examiner. Delaware's Office of Chief Medical Examiner will try to continue its tradition to serve as a model for other states and possibly other countries to follow.

In 1194, the coroner system was formally established in England with the original interest in death to protect the financial interest of the crown. This coroner system was brought to the United States during the early 1600s where the first recorded autopsy was performed in Massachusetts in 1647. Significant changes were made to improve upon the coroner system. In 1877, the first medical examiner system was established in the state of Massachusetts requiring that the coroner be supplanted by a physician known as a medical examiner. Using the system established in Massachusetts as a model, New York City developed an improved medical examiner system in 1915. The improvements made by New York City, under the leadership of men such as Drs. Charles Norris and Alex Gettler, essentially laid down the foundation for medical examiner systems and forensic toxicology throughout the country. Part II of this series will begin in Maryland. Maryland soon followed in New York City's footsteps and in 1939 developed the first statewide medical examiner system in the U.S. Influenced by systems such as Maryland's and New York City's, Delaware established a medical examiner system in 1955 to work alongside of the pre-existing coroner system. It was not until about a decade later in 1964 that the system became successful under the leadership of Dr. All Z. Hamell. In 1970, after 15 years of uphill battles with supporters of the antiquated coroner system, it was abolished, resulting in a statewide medical examiner system. Today, Delaware's medical examiner system has one of the best medicolegal investigative facilities in the country, complete with its own forensic sciences laboratory under the jurisdiction of a Chief Medical Examiner. Delaware's Office of Chief Medical Examiner will try to continue its tradition to serve as a model for other states and possibly other countries to follow.

In recent years, the enactment of uniform national regulations concerning postmortem examination has become a persistent demand. There is strong criticism of the reliability of coroner's inquest. The education of most of the coroners in forensic medicine is found to be insufficient, and many experts report that medical examiners partly are neglectful for the inquest. The classification of the manner of death is also said to be deficient, the rate of misdiagnosis being only little below 50%. Thus much emphasis is put on demanding a reinforced training of doctors in the field of the external examination of corpses. But only few of those reports make allowance for the fact that most of the present deficiencies have their origin in the 19th century. As a matter of fact, from the outset the practice of coroner's inquest gave rise to criticism. Thus the present article traces the historical roots of postmortem examination in Germany. Special emphasis is placed on a comparison between the infancies of coroner's inquest and the current state. Actual and historical imperfections in the system of postmortem examination and striking similarities are pointed out.

Decision on the founding of the pathoanatomic service of the public health divisions, and the appointment of Dr. Ljudevit Jurak for the first prosector in 1913, is considered the beginning of the organized development of pathologic anatomy in Croatia. The aim of this paper was to investigate why this decision was made only in 1913, i.e. to find so far unknown answers to the questions who, when and with which motives made the initiative to found this important institution. Results and conclusions presented are based mainly on the data gathered by searching through "Lijecnicki vjesnik" from 1877 through 1914, complemented with information from the available archives, as well as the facts published in newspapers and historical medical contributions. The conducted research indicates that at the beginning of the twentieth century the need for public pathoanatomic service and prosector in the city of Zagreb most strongly imposed itself in the setting of clinical practice, first of all hospitals, and demands in medical jurisprudence, and much less as the result of administrative regulations on gathering statistics on death causes introduced in the kingdom of Croatia and Slavonia at the end of the nineteenth century. The Medical Association of the kingdom of Croatia and Slavonia indisputably had the most important role in the founding of the organized pathoanatomic service in the city of Zagreb, and also in the development of pathologic anatomy in Croatia. The filed requests which the Medical Association sent to the government and published in "Lijecnicki vjesnik" from 1903 to 1911 reveal that the positions of the physicians regarding the importance of pathologic anatomy for the development of modern pathoanatomic and bacteriologic diagnostics, for the investigation of the causes of death including the violent death, as well as for the development of scientific research in Croatia, were in accordance with the most advanced notions of their colleagues in Europe. The history of the struggle to found the public pathoanatomic service in Zagreb highlights the endeavors and need of Croatian physicians to update the routine professional, public health and scientific work. At the same time these were related with their striving to found clinical bases and scientific divisions necessary for the establishment of the medical school in Zagreb. The work of prosector and pathoanatomic service is being considered in the function of teaching pathological anatomy at the medical school in Zagreb, as well as in the function of teaching medical jurisprudence at the level of the University of Zagreb, i.e. the existent Law School and the future medical school. Difficulties in the realization of these endeavors can partly be explained by the lack of understanding and interest on the part of administrative and political authorities. However, one of the possible reasons for the delay of the decision on founding pathoanatomic service in the city of Zagreb till 1913 may be the fact that among Croatian physicians until 1911 there were no experts in pathologic anatomy who might have satisfied the requirements, although in that period there were no obstacles for such service in Zagreb to be entrusted to any professional, citizen of the Austro-Hungarian Monarchy. All taken into account, Dr, Ljudevit Jurak (1881-1945) was the only Croat who in the period from 1911 to 1913, when he was elected the prosector of the public pathoanatomic service in the city of Zagreb, met high requirements for the professional, scientific and research work, as well as for teaching in the field of pathologic anatomy and medical jurisprudence at the university.

Context: Medical legal investigations in the United States (primarily unnatural or suspected unnatural deaths) are carried out by medical examiner or coroner systems. Medical examiners-usually physicians and generally with training in pathology, medicolegal death investigation, and performance of forensic autopsies-generally have greater expertise in unnatural death investigations than do coroners., Objective: To document the locations and implementation year for states and counties that have medical examiner systems that have replaced coroner systems or that are defined in statute and assist coroners in their investigations., Design: Review of published information and national survey in 1997., Setting: United States., Participants: County medical examiners and state medical examiners or their administrators., Main Outcome Measures: The location of states and counties with medical examiner systems, the implementation year for each system, and the proportion of counties and population served by medical examiner systems., Results: A total of 79 of 91 county medical examiners responded. A total of 36 states have at least 1 medical examiner system at the county, district, or state level in which there is no coroner involved in the death investigation process. Only 22 states have medical examiner death investigation systems in place and have no coroners in the state. Among 13 states in which some counties have coroner systems and some have medical examiner systems, medical examiner systems exist in 8% of counties and serve 43% of the population. Medical examiner systems that operate without coroner involvement serve about 48% of the population nationwide. Few state or county medical examiner systems have been implemented since 1990., Conclusions: In this century, medical examiner systems have gradually replaced coroner systems, but such change has slowed in recent years, with medical examiner systems now serving about 48% of the national population.

Every death is unique, but deaths also share similar features that allow them to be grouped into categories. Since its initial description over 800 years ago, the position of coroner has been charged with the determination of manner of death. This determination has been made by examination into the circumstances surrounding death and of wounds on the surface of the body. Over the years, physicians have gained sufficient understanding of the body such that the autopsy became an important part of a death investigation. With additional time, laws were changed so that individuals charged with the determination of manner of death were required to have appropriate training. Death certification is the means by which deaths are grouped together according to similar characteristics. The practice of death certification has led to effective public health programs and the advancement of medical science. The addition of manner of death to the death certificate is an American contribution to vital statistics registration. The purpose of the autopsy report differs from that of the death certificate; the report fully addresses the unique aspects of a death, while the certificate captures the essence of the circumstances surrounding death in a few words.

Coroner is an ancient office, dating back centuries in England; originally financial officers, coroners over time become medicolegal investigators. Coroners in early Massachusetts functioned under English common law and, later, under statute. However, studies of early coroners and inquests are not common, and many details of how coroners actually functioned are unknown. A previously unpublished set of 19th-century Massachusetts inquest records discloses details of coroner function, including administrative and financial details, social conditions surrounding inquests, and increasing use of medical and toxicologic testimony.

Newfoundland's former chief forensic pathologist is pleased that the provincial government has adopted a new medical examiner's act that he helped develop. He hopes the new act will help clear up confusion about who does what when a body is found in the province.

The author's experience and impressions of the proceedings of the Office of the Medical Examiner, Cook County, Chicago, Illinois, United States of America are discussed. This experience demonstrates the limitations of the South African medicolegal system, particularly its lack of credibility among the greater proportion of the community. The medical examiner's office in the United States, being independent, enjoys credibility and the confidence of the community at large and of the courts, without alienating the police or other law enforcement agencies. These organizations feature in the medical examiner system by courtesy of the chief medical examiner. In the United States two types of investigative medicolegal systems coexist, sometimes in the same state or adjacent country: the coroner system (unlike the English coroner system) and the medical examiner system. Of the two, the coroner system is the older, is not always headed by a medically trained person, and is a political appointment. This system has been accused of lacking autonomy and scientific objectivity.