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Med Leg J OnlineFirst, published on May 28, 2014 as doi:10.1177/0025817214533759

Original Article

Medico-legal autopsy of 1355 unclaimed dead bodies brought to a tertiary care hospital in Delhi, India (2006–2012)

Medico-Legal Journal 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025817214533759 mlj.sagepub.com

Chopra Saurav, Garg Aayushi, C Behera, Krishna Karthik, T Millo and SK Gupta

Abstract In India, it is estimated that about 13 million people are homeless. As these individuals have no close acquaintances, in the event of death, their bodies remain unclaimed. These unclaimed corpses pose a major challenge for the local law enforcement agencies in identification and thus become an obstacle in solving the cases of missing persons. We sought to review the autopsy characteristics and causes of death in the unclaimed/unidentified bodies autopsied at the All India Institute of Medical Sciences (AIIMS) from 2006 to 2012. Among the total of 11,786 cases autopsied during the year 2006 to 2012, 1335 (11%) were unclaimed. Most of the cases were males (91%) with a male-to-female ratio of 9:1. Mean age of the cohort was 43 years (range, 1–85 years). Natural events were the foremost cause of death and were more commonly seen in males. While accidental, suicidal and homicidal modes were common in younger age groups; natural manner of death predominated in the elderly. Most of the cases were found dead on the roadside. This paper also compares with the previous study in the same set-up during the time period 2001 to 2005. The authors believe that knowledge about the existing healthcare facilities need to be reinforced and their utilisation promoted.

Keywords Unclaimed dead bodies, medico-legal, healthcare, India

Introduction India is a developing country where nearly 13 million people are estimated to be homeless.1 There are primarily two reasons for homelessness. The chief reason is migration of extremely poor people from the nearby villages in search of better job opportunities to a large metropolitan city like Delhi, while the second reason is the natural disasters that uproot the people from their original homes and force them to migrate to cities for survival. Whatever the reason is, most of these people do not have any government identities.2 Moreover as usually a single male member in the family is the one who migrates, he lacks acquaintances in the city. In an event of death, such bodies remain unclaimed after death. The same reason also accounts for the males being predominant and females constituting only 7– 10% of the homeless population.3 Most of these people are daily wage workers or rickshaw pullers. The majority of them occupy the footpaths along the roadside. The other common places occupied by them are workplaces, temples, public parks and railway platforms.2

According to the Delhi Anatomy Act, 1953, an ‘‘unclaimed body’’ refers to ‘‘the body of a person who dies in a hospital, prison or public place, which has not been claimed by any near relatives or personal friends within such time period as may be prescribed.’’4 According to the Delhi police manual, a dead body is declared unclaimed after 72 h of death and police are legally authorised to dispose the body after that duration.5 The unidentified/unclaimed corpses pose a major challenge for the local law enforcement agencies. They become an obstacle in the primary task of identification due to lack of sufficient funds and infrastructure. Although the police try to trace the claimants by publishing photographs and relevant details of the deceased in the print and visual media, the efforts are Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi, India Corresponding author: C Behera, Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi 110029, India. Email: [email protected]

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Figure 1. Change (trend) in the total number of unclaimed deaths from 2006 to 2012.

rarely successful. In India, all unidentified individuals brought dead to the hospital or who die during the course of treatment in the hospital will be subjected to medico-legal autopsy. The primary aim of such autopsy would be to assist in identification of the dead body (by examination of clothings, tattoo marks, scar marks, etc) as well as to know other characteristics such as cause of death, manner of death, etc. The medicolegal autopsy is performed once the waiting period of 72 h does not yield any claimants and the body is disposed of by the police as per the protocol. DNA analysis of deceased individuals is rarely performed before the disposal which could lead to medico-legal complications, if the claimants arrive after the body has been disposed. It is of utmost importance to understand the common causes of death in these people and target the reduction in certain preventable causes. The aim of this study was to review the autopsy characteristics and causes of death in the unclaimed/unidentified bodies.

Materials and methods The retrospective records of all the autopsies conducted at the All India Institute of Medical Sciences (AIIMS) from 2006 to 2012 were searched for unclaimed/unidentified corpses. The details of these cases were sourced from the autopsy records and the inquest papers of the investigating officer. The unclaimed cases of neonates and infants were excluded from the study. Analysis was performed using Stata 11.2 version (StataCorp, College Station, Texas).

Results A total of 11,786 cases of medico-legal deaths were autopsied at AIIMS from 2006 to 2012. Of these, 1335 (11%) were unclaimed dead persons. Figure 1 shows variation in the number of cases reviewed per year. The characteristics of the cases stratified according to the manner of death are shown in Table 1. Most of the

Table 1. Characteristics of the cases stratified according to manner of death (natural/unnatural). Variable Age 1–20 21–40 41–60 >60 Sex Male Female Injury Present Not present Decomposition Skeletonised Not skeletonised Seasons Summer Winter

Natural (n ¼ 875)

Unnatural (n ¼ 455)

p 0.000

13 325 423 114

41 300 99 15

814 61

402 53

0.004

0.000 25 850

360 95

2 873

7 448

381 494

205 250

0.001

0.598

cases were males (91%). Mean age of the cohort was 43 years (range, 1–85 years). Majority of the unclaimed corpses were in the age group of 21–40 years (47%), followed by 41–60 years (39%) and >60 years (10%), while only 4% of cases were aged less than 21 years. Table 2 shows the manner and cause of death in all cases. Natural events were the foremost manner of death (66%), followed by accidental manner (25%). Cause and mode of death could not be ascertained in five cases due to highly decomposed bodies and/or missing body parts. Age wise and gender distribution of cases according to the manner of death (natural/unnatural) is shown in Table 1. Natural deaths were more commonly seen in males as compared to females.

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Table 2. Stratification of the cases according to the cause of death. Cause of death Natural (n ¼ 875) Pneumonia Chronic lung disease Sepsis Cardiovascular disease Chronic liver disease Aspiration Heat stroke Neoplasm Meningo-encephalitis Unnatural (n ¼ 455) Accidental (n ¼ 331) Hemorrhagic shock Severe head injury Drowning Electrocution Homicidal (n ¼ 51) Severe head injury Strangulation Hemorrhagic shock Poisoning Drowning Burns Suicidal (n ¼ 49) Poisoning Hanging Drowning Burns Head injury (fall) Miscellaneous (n ¼ 29) Intoxication (alcohol/narcotic) Unexplained (n ¼ 5)

Table 3. Stratification of the cases according to the location of corpse.

Number of cases

Percentage

581 182 79 14 12 3 2 1 1

43.5 13.6 5.9 1.0 0.9 0.2 0.1 0.1 0.1

164 143 20 4

12.3 10.7 1.5 0.3

in 16% of cases autopsied. Blood and/or bone samples for DNA analysis were collected in 7% of cases.

19 12 9 7 2 2

1.4 0.9 0.7 0.5 0.1 0.1

23 15 4 4 3

1.7 1.1 0.3 0.3 0.2

24

1.8

Our study on homeless/unidentified dead bodies confirms and expands the previous literature. We found male preponderance in our study with male-to-female ratio of 10.6:1. Similar male predominance has been reported by previous studies.6–10 Male predominance could be attributed to the fact that most of the migrants are males. Similar to the previous reports, maximum mortality was reported in the age group of 21 to 40 years.10 We observed that natural events accounted for the majority of the cases. Although Raghavendra Babu et al10 reported contrary findings, most of the available studies support the predominance of natural causes of death.6,7 The most common natural causes of death in our cases were acute/chronic lung diseases. The individuals who are homeless residing on the roadside expose themselves to the hazards of pollution and climatic variations with no medical aid. They cannot afford to buy medications and neither can the government cover such individuals under the free medical schemes. Also many of these homeless individuals are known to indulge in substance abuse and high-risk sexual behaviour.11,12 This predisposes them to acquire human immunodeficiency virus (HIV) infection. Secondary immune deficiency along with cigarette/bidi smoking may account for high incidence of both acute and chronic lung diseases. Accidental causes were identified as the second most common cause of mortality in our study. Among accidental causes, road traffic accidents leading to severe head injury and/or hemorrhagic shock accounted for the majority of the cases. People occupying the

Also, the proportion of deaths occurring due to natural events increased with age. While accidental, suicidal and homicidal modes were common in younger age groups, natural modes predominated in the elderly population. The majority of the cases were homeless and were found along the roadside. Table 3 shows the various locations of recovery of the corpses. Special identifying features such as a body tattoo were found in only 144 (11%) cases. Amongst these, most of the tattoos read names. The majority (63%) of the corpses were reported to have a thin build. Nearly 9% of the bodies were found partially or completely naked. The majority apparently belonged to lower socio-economic status. Toxicological analysis on viscera was performed

Place of corpse

Number

Percentage

Roadside Railway track/station Public park River Bus stand Hospital Temple Forest Abandoned building Garbage bin Others

892 108 61 58 55 52 47 27 11 4 15

66.8 8.1 4.6 4.3 4.1 3.9 3.5 2.0 0.8 0.3 1.1

Discussion

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pavement along the streets were predisposed to a high risk of road traffic accidents. Also the majority of them, being migrants from neighbouring villages, are probably not well acquainted with the traffic rules of the city making them prone to accidents. The decrease in visibility due to night and early morning fog also contributes to such fatalities. Homicidal and suicidal causes were not uncommon. As the majority of these individuals are illiterate and lack knowledge of the law, execution of homicide is unchecked. Many of these individuals get involved in petty crimes like robbery and fights. Poverty and hunger lead to antisocial activity that is promoted by substance abuse. The mental distress caused by extreme poverty superimposed by loneliness may account for most of the suicidal cases. We found the majority of the deaths to occur during the winter months. This conforms with some previous reports.7,13 The incidence as well as morbidity of acute pneumonia is increased manyfold during winters. Moreover the chronic lung diseases may exacerbate during this time of year. Starvation contributes to exacerbation of natural diseases due to lack of immunity. As shown in Table 3, most of the corpses were recovered from the roadside (67%). This can be accounted for by the lack of shelter homes in the city and by the fact that homeless people are driven away from places like railway stations, bus stands, public parks and temples. This study was compared to a similar study conducted in the same set-up during the time period 2001 to 2005.9 It was found that most of the deceased were male (n ¼ 645, 87.75%) with an M:F ratio of 7.17:1.The commonest age group involved was 31–40 years (n ¼ 228, 31.02%). Most victims (n ¼ 451, 61.36%) died from natural causes, followed by accidental deaths (n ¼ 233, 31.70%) and homicides (n ¼ 26, 3.54%). The majority of deaths were reported in the rainy season (n ¼ 284, 38.64%). The deceased were mostly recovered from the road or road side (n ¼ 352, 47.89%). It is clear that nothing much has changed for the homeless unclaimed individuals in the last decade. The comparison of both the previous data and the data from the current study raises concerns for health professionals. Acute and chronic lung diseases were identified as the single most common cause of preventable death among homeless people. The most probable reason aggravating the situation is lack of knowledge and hence limited access to the medical facilities provided by the government. Measures are needed to promote the utilisation of the same. Government and NonGovernmental Organisations should take up measures to provide shelter to the homeless individuals. Provision of night shelters and issue of government identities will offer social security to some extent and

might effectively curtail the problem of unclaimed dead bodies. A complete database of homeless individuals including the DNA profile would decrease the burden on the law enforcement agencies in the process of identification in the event of death. The proportion of migration to the cities can be controlled with governmental policies targeted to provide basic amenities to the villages and towns. In conclusion, we found that homeless and unclaimed people in Delhi were at an increased risk of mortality. Though the predominant mode of death was by natural causes, unnatural modes especially accidents were important as well. Knowledge about the existing healthcare facilities needs to be reinforced and their utilisation needs to be promoted in order to tackle the medico-legal problem of unclaimed dead bodies. References 1. Causes of Homelessness. Available at: www.tkf.org.in/ blog/homelessness_causes_india_ngo_support/ (accessed 22 January 2014). 2. Project Management Unit, GNCTD-UNDP Project, Administrative Reforms Department, Vikas BhawanII, Delhi. Homeless survey 2010. Available at: http:// www.homelessdelhi.org/uploads/3/2/6/6/3266011/homeless_survey_report_draft.pdf(accessed 1 January 2014). 3. Living rough-Surviving the City Streets, a Study of Homeless Populations. Delhi, Chennai, Madurai and Patna. Available at: www.actionaidindia.org/homeless_ Shiver_delhi.htm (accessed 15 January 2014). 4. The Delhi Anatomy Act. 21 April 1953. 5. Koshy K. Punjab police rules. Vol. III, Delhi: The Bright Law House, 1992, pp.1078–1083. 6. Bu¨yu¨k Y, Uzu¨n I, Eke M, et al. G. Homeless deaths in Istanbul, Turkey. J Forensic Leg Med 2008; 15: 318–321. 7. Altun G, Yilmaz A and Azmak D. Deaths among homeless people in Istanbul. Forensic Sci Int 1999; 99: 143–147. 8. Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med 2013; 173: 189–195. 9. Kumar A, Lalwani S, Behera C, et al. Deaths of homeless unclaimed persons in South Delhi (2001–2005): a retrospective review. Med Sci Law 2009; 49: 46–50. 10. Raghavendra Babu YP, Joseph N and Kadur K. Mortality among homeless and unclaimed bodies in Mangalore city – an insight. J Forensic Leg Med 2012; 19: 321–323. 11. Centres for Disease Control. Deaths among homeless persons – San Fransisco. JAMA 1992; 267: 484–485. 12. Schanzer B, Dominguez B, Shrout PE, et al. Homelessness, health status and health care use. Am J Pub Health 2007; 97: 464–469. 13. Ohsaka T, Sakai Y, Kuroda K, et al. A survey of death of homeless people in Osaka city. Nippon Koshu Eisei Zaasshi 2003; 50: 686–696.

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Medico-legal autopsy of 1355 unclaimed dead bodies brought to a tertiary care hospital in Delhi, India (2006-2012).

In India, it is estimated that about 13 million people are homeless. As these individuals have no close acquaintances, in the event of death, their bo...
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