Legal Medicine 16 (2014) 258–263
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Trends in forensic autopsy in Chiba prefecture over the past decade Go Inokuchi ⇑, Kenji Ishihara, Mutsumi Hayakawa, Daisuke Yajima, Yohsuke Makino, Ayumi Motomura, Fumiko Chiba, Suguru Torimitsu, Hirotaro Iwase Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
a r t i c l e
i n f o
Article history: Received 17 March 2014 Received in revised form 9 May 2014 Accepted 1 June 2014 Available online 20 June 2014 Keywords: Forensic autopsy Medicolegal autopsy Death investigation Unusual death Unnatural death
a b s t r a c t The death investigation system in Japan is in the midst of a great transformation. As part of efforts to revise this system, in this study we analyzed the reasons the police refer unnatural death cases for forensic autopsy and, from an understanding of the trends of such referrals, we discuss the future direction of handling unnatural deaths in our country. For 1618 forensic autopsy cases handled by the First Investigation Division of Chiba Prefectural Police that were referred to our institution for forensic autopsy between 2003 and 2012, we tallied the number of autopsies by sex, age group, and reason for forensic autopsy for each year and investigated trends in the referrals over time. The results revealed that the number of autopsies increased annually from 2003 to 2012, with a marked increase from 2010. The number of autopsies increased particularly for cases of suspected criminal deaths, where it was unclear to the police before the forensic autopsy whether or not the death resulted from a criminal act. Our findings suggest that the number of forensic autopsies will continue to increase into the future in Chiba prefecture, and is a trend that is inevitable if we are to prevent criminal death cases from being overlooked. Although referrals for forensic autopsy in Japan are made only when criminal activity is suspected, the original purpose of death investigations is not only to avoid overlooking crimes, but also to flag public health issues. Therefore, together with the police, we need to review the original purpose and conduct more in-depth discussions about when referrals are necessary. Ó 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The death investigation system in Japan is in the midst of a great transformation. The inadequacy of the system and the very 1ow autopsy rate in our country have been pointed out since the early 2000s, and in 2007, the House of Representatives embarked on systemic reform. Very soon after, a case involving the death of a young sumo wrestler was deemed solely by the police, on the basis of an external examination of the body only, to be a natural death; no forensic autopsy was requested in what was later established to be a case of accidental perpetration of death. This socalled ‘‘Tokitsukaze sumo stable scandal’’ highlighted the need for systemic improvement of the country’s death investigation system, including the relevance and necessity of forensic autopsy in certain cases. In response to this situation, a Study Group on the Death Investigation System to Prevent Overlooking Causes of Death by Criminal Acts was set up by the National Police Agency in 2010, and two laws concerning the death investigation system ⇑ Corresponding author. Tel.: +81 43 226 2078; fax: +81 43 226 2079. E-mail address: [email protected] (G. Inokuchi). http://dx.doi.org/10.1016/j.legalmed.2014.06.001 1344-6223/Ó 2014 Elsevier Ireland Ltd. All rights reserved.
were enacted in 2012: the Act on Cause of Death Investigations and Identification of Bodies Handled by the Police and the Act on the Promotion of Cause of Death Investigations. Discussions have since been extended to cover the full spectrum of death investigation purposes, which include public health issues, by the Committee for the Promotion of Cause of Death Investigations set up by the Cabinet Office. Against this background, and given the fact that the police are handling more bodies [1], the number of forensic autopsies has been increasing annually, not only in Chiba prefecture but across Japan. As part of efforts to revise the death investigation system, we analyzed the reasons the police refer unnatural death cases for forensic autopsy and determined the trends of such referrals. From the trends identified, we discuss the future direction of handling unnatural deaths in our country. Japan’s death investigation system has two paths to medicolegal autopsy (Fig. 1): one is through forensic autopsy, which is based on criminal justice (Section 168 of the Code of Criminal Procedures) and is performed by departments of legal medicine at universities, the other path is through administrative autopsy or consent autopsy (requiring consent from the bereaved family),
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Fig. 1. Flow chart of Japan’s death investigation system, based on the number of bodies handled by the police and the autopsy rate for 2010 [2].
both of which are based on public health laws (Sections 8 and 7 of the Act Concerning Dissection and Preservation of a Dead Body). Administrative autopsy was introduced in large cities only, such as Tokyo, after World War II and is performed mainly by medical examiners. Consent autopsy is performed in those areas with no medical examiner’s office. As shown in Fig. 1, unusual deaths or reportable deaths are initially reported to the police, who then inspect the circumstances surrounding the death in each case and perform an external examination of the body to determine whether or not the death resulted from criminal activity. Reportable deaths are divided into the following three categories: criminal deaths, suspicious deaths (when it is unclear whether a death resulted from a criminal act), and non-criminal deaths. Based on the Code of Criminal Procedures, a forensic autopsy is requested in all criminal deaths, while in suspicious deaths, a specific postmortem investigation and an external body examination are conducted by a special police inspector if he or she deems necessary. This special police inspector has a role somewhat similar to that of a coroner or medical examiner in other countries but is not a medical doctor and is a member of the police force. The role of the special police inspector is not defined by law; however, it is generally recognized in Japan. These inspectors are selected from the First Investigation Division of Police and complete training in postmortem investigation including external examination. For deaths deemed non-suspicious or non-criminal by a special police inspector, an administrative autopsy or consent autopsy is performed in accordance with the Act Concerning Dissection and Preservation of a Dead Body when regarded as appropriate to do so. From April 2013, autopsies in accordance with the Act on Cause of Death Investigations and Identification of Bodies Handled by the Police were also started. An important point of note is that Japanese forensic autopsy is legally performed only when a special police inspector deems the death to be associated with criminal activity. For example, autopsy is rarely performed in the initial investigation when a case is judged as suicide. The decision of whether or not to perform a forensic autopsy is made solely by the special police inspector.
Several legal and social issues associated with Japan’s death investigation system have been identified. As shown in Fig. 1, the autopsy rate for unnatural/reportable deaths is extremely low in Japan. Moreover, administrative and consent autopsies are rarely performed. As mentioned above, forensic autopsy is performed only in cases judged to be associated with criminal activity in those areas without a medical examiner’s office such as Chiba prefecture. The majority of bodies, which are judged to result from non-criminal deaths in the initial police investigation, are processed without responsibly determining the cause of death: no medical or scientific evidence is collected and the cause is judged by external examination of the body only. It is in this context that cases of criminal or accidental perpetration of death have been overlooked in Japan’s death investigation system. Overlooked cases that have become apparent and have developed into a social issue in Japan [2] include those with no external findings, such as in cases of criminal intoxication, suffocation, accidental carbon monoxide intoxication due to faulty water heaters, and the Tokitsukaze sumo stable scandal mentioned above.
2. Materials and methods We investigated 1618 forensic autopsy cases handled by the First Investigation Division of Chiba Prefectural Police that were referred to our institution for forensic autopsy between 2003 and 2012. Cadavers handled by the Traffic Division of Chiba Prefectural Police, the Public Prosecutors Office, and the Coast Guard were excluded. Before conducting the autopsies, we obtained detailed case information from the police (i.e., name, sex, age, circumstances of death, background to the incident, mechanism of death, and reason for requesting a forensic autopsy) and recorded these information in the autopsy register. From this register, we tallied by year the number of autopsies by sex, age group, and reason for forensic autopsy and investigated trends in the referrals over time. It should be noted that some forensic autopsies handled by Chiba Prefectural Police are performed at institutions other than ours, but the number of bodies and autopsies used here to calculate the autopsy rate in Chiba prefecture includes these other cases.
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2.1. Classification by reason for forensic autopsy Although the need to perform a forensic autopsy had already been decided by a special police inspector, we sorted forensic cases into the following seven categories of reason for forensic autopsy after considering the contents described in the autopsy register (circumstances of death and situation leading to autopsy). 1. Obvious criminal death witnessed or confessed criminal death death due to injury obviously inflicted by another person (e.g., stab wound or ligature mark) 2. Suspicious death group 1 (strongly suspected criminal death) death with significant injury suggesting harm caused by another person based on external body or computed tomography findings death immediately after minor assault (i.e., the presence or absence of a correlation) death attributed to a person accused of a specific crime (e.g., professional negligence resulting in death or abandonment by a responsible person resulting in death) death suspected to involve a murder–suicide (not to be confused with double suicide) infant death (i.e., confirmation of a live birth, as opposed to a stillbirth) 3. Suspicious death group 2 (suspected criminal death or criminal death not ruled out) death due to unfortunate circumstances (e.g., history of illegal drug use, poor family relationships, or problematic associations), even if suicide or death due to self-negligence is suspected situation leading to death is unclear, even if injury or circumstances suggesting harm by another person are not detected reason for the autopsy is unclear from the standpoint of criminality based on the description in the autopsy register 4. Suspicious death group 3 (improbable criminal death or noncriminal death) consideration for or at the request of the bereaved family death with the need to distinguish between intrinsic and extrinsic factors for life insurance purposes (e.g., death in the bath or death due to a fall) death due to a possible civil conflict, even if no criminal responsibility can be established (e.g., a resident of a care facility died after staff looked away for a few seconds) 5. Unidentified death 6. Medically related death death during medical procedures suspected death due to malpractice death following discharge 7. Work-related death death while working death due to working environment factor (e.g., death in an explosion accident or by falling from a height)
Fig. 2. Number of forensic autopsies handled by the First Investigation Division of Chiba Prefectural Police at our institution.
Fig. 3. Change in the male-to-female ratio for forensic autopsy.
3.2. Change in the male-to-female ratio for the forensic autopsies conducted Fig. 3 shows that the male-to-female ratio during the investigation period changed little, at approximately 60:40, over the 10year period.
3.3. Change in age structure for the forensic autopsies conducted Fig. 4 shows the change in age structure for the forensic autopsies performed between 2003 and 2012. In 2012, the number of autopsies performed for the >30s age group increased markedly compared with that in 2003, while that for young people
3. Results 3.1. Change in the number of forensic autopsies conducted Fig. 2 shows the number of autopsies performed in Chiba prefecture increased annually from 2003 to 2012, with a marked increase evident from 2010. The rate of forensic autopsies for cases handled by the police in the prefecture was 2.7% in 2010 (8010 bodies handled by the police and 213 forensic autopsies performed) and 4.1% in 2012 (8153 and 336, respectively).
Fig. 4. Change in the number of autopsies performed between 2003 and 2012 according to age structure.
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(aged < 20 years) did not change significantly. The number of annual autopsies performed on young people was around 20 each year. 3.4. Trends in the autopsy rate according to reason for forensic autopsy Trends in the number of autopsies performed according to the reason for forensic autopsy are shown in Table 1 and Fig. 5. Over the 10-year period, the number of autopsies for suspicious death group 2 increased in all seven categories and, notably, the proportion of this group among all autopsies rose 2-fold, from 25.5% in 2003 (vs. 27.3% for obvious criminal deaths) to 51.2% (vs. 5.5% for obvious criminal deaths) in 2012. In this group, the number of autopsies due to suspected suicide by hanging, carbon monoxide poisoning from coal briquettes, or fire increased markedly from 2010 to 2012 (Fig. 6). The combined number of autopsies for the categories obvious criminal death and suspicious death group 1 showed no particular trends, with around 50–60 autopsies carried out each year. The number of autopsies for suspicious death group 3 and unidentified death showed an increasing trend. The number of autopsies for medically related death and work-related death showed no particular trends.
Fig. 5. Change in the number of autopsies for deaths categorized as obvious criminal death and suspicious death.
4. Discussion 4.1. Change in the number of forensic autopsies: an increased number of suspicious death group 2 cases According to a statement issued by the National Police Agency, the number of forensic autopsies has been increasing across Japan, especially since 2010 (6569 autopsies in 2009 vs. 8520 autopsies in 2012) [1]. This increasing trend coincides with an increase in the number of death scenes attended by special police inspectors which has occurred following attention given to overlooked criminal death cases. In this study, a similar tendency was recognized in Chiba prefecture. In the prefecture, a review of the reasons for forensic autopsies revealed that the number of suspicious death group 2 cases (suspected criminal death or criminal death not ruled out) has significantly increased, whereas the numbers of obvious criminal deaths and suspicious death group 1 cases (strongly suspected criminal death) were mostly unchanged. This indicates that most of the increased number of forensic autopsies constitutes suspicious deaths.
Fig. 6. Change in the number of autopsies for deaths due to suspected suicide by hanging, carbon monoxide poisoning by coal briquettes, and fire.
The specific reasons for requesting forensic autopsy in the suspicious death group 2 varied on a case-by-case basis. Most cases were referred for autopsy when criminal activity was suspected, even in the slightest, by the police or when the circumstances surrounding natural death, suicide, or self-negligence were unclear, as indicated by the classification group name. Looked at another way,
Table 1 Trends in the number of autopsies classified by reason for forensic autopsy. Reason for forensic autopsy
Obvious Criminal death Suspicious Death group 1 Suspicious Death group 2 Suspicious Death group 3 Unidentified Death Medically Related death Work-related Death Total
Year 2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
30 (27.3) 32 (29.1) 28 (25.5) 0 (0) 11 (10) 9 (8.2) 0 (0) 110
19 (17.0) 24 (21.4) 30 (26.8) 1 (0.9) 26 (23.2) 7 (6.3) 5 (4.5) 112
26 (19.8) 17 (13.0) 41 (31.3) 5 (3.8) 23 (17.6) 19 (14.5) 0 (0) 131
18 (12.9) 29 (20.9) 28 (20.1) 7 (5.0) 43 (30.9) 11 (7.9) 3 (2.2) 139
25 (18.5) 19 (14.1) 47 (34.8) 5 (3.7) 27 (20.0) 8 (5.9) 4 (3.0) 135
28 (17.9) 21 (13.5) 54 (34.6) 2 (1.3) 32 (20.5) 13 (8.3) 6 (3.8) 156
31 (20.0) 21 (13.5) 45 (29.0) 8 (5.2) 37 (23.9) 9 (5.8) 4 (2.6) 155
20 (10.9) 31 (16.8) 74 (40.2) 13 (7.1) 33 (17.9) 9 (4.9) 4 (2.2) 184
26 (12.7) 34 (16.7) 74 (36.3) 11 (5.4) 50 (24.5) 8 (3.9) 1 (0.5) 204
16 (5.5) 47 (16.3) 148 (51.2) 16 (5.5) 39 (13.5) 15 (5.2) 8 (2.8) 289
Numbers in parentheses indicate the percentage of autopsies in each category relative to total autopsies (%) in each year.
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this finding suggests that a number of these deaths may have been previously judged as non-criminal deaths in the initial police investigation and were thus not referred for forensic autopsy. According to an official announcement made by the police, 43 cases of criminal death have been overlooked in Japan since 1998 [2]. In half of these cases the cause of death was incorrectly determined as not being related to criminal activity in the initial investigation. Therefore, it would seem that the increased number of suspicious death group 2 cases was the result of spreading awareness that, first, more accurate judgments can be made and, second, the overlooking of criminal cases can be avoided by performing detailed forensic investigations such as autopsy and toxicology. In Chiba prefecture, a case of murder disguised as suicide by hanging was exposed in 2011 [3]. It was initially judged as a non-criminal death (suicide) in the initial investigation by the police and no autopsy was performed. In addition, in several prefectures, the modus operandi of murder disguised as suicide by carbon monoxide poisoning from coal briquettes, which made the headlines in 2010 as a series of murders by a marriage swindler to exploit insurance money [4], was revealed after more than one victim was found. In a detailed review of the suspicious death group 2 category, there was a clear increase in the number of suspected suicide deaths by hanging, coal briquettes, or fire for 2010 and 2012, an increase which undoubtedly reflects the attention drawn by these high-profile overlooked criminal cases. The remaining half of the overlooked criminal death cases announced by the police resulted from their insufficient initial investigations (e.g., inquiries into insurance matters were not made, toxicological tests were not performed, or insufficient corroborating evidence was collected), even though the actual causes of death had been correctly established. Murder disguised as suicide by hanging or poisoning by coal briquettes fall into this category. The very existence of this category suggests that the initial investigation by the police, along with determining the correct cause of death, is critical to ensuring that criminal deaths are not overlooked. The purpose of forensic investigations, including autopsy, in these kinds of cases is also to preserve evidence for court proceedings and to determine the correct cause of death. Therefore, it appears that the increasing number of suspicious death group 2 cases reflects the decision of the special police inspector, who requests autopsy, to preserve the evidence and take precautions against not overlooking possible criminal involvement. From the standpoint of preventing overlooked criminal deaths in Chiba prefecture, our findings indicate that the autopsy rate is continuing to rise alongside the increasing number of suspicious death group 2 cases. However, the autopsy rate for reportable deaths is still low compared with that at forensic institutions in other developed countries (e.g., 89.1% in Sweden, 53.3% in Victoria, Australia, 19.3% in Hamburg, Germany) or in Akita prefecture, which has the highest autopsy rate in Japan at 13.8% [2]. The classification used in this study (criminal death, suspicious death, and non-criminal death), which is based on the specific death investigation system in Japan, may appear strange to some because it is possible in this system for unnatural deaths to be classified as non-criminal deaths purely on the basis of an external body examination without a detailed forensic investigation including autopsy [5]. Given the above, the concept of Japan’s death investigation system defined by the Code of Criminal Procedures needs to be reconsidered. 4.2. Increased number of unnatural death group 3 cases In Japan, forensic autopsy is basically required only when criminality is suspected. However, the number of suspicious death group 3 cases, which are judged by the police as improbable criminal death or non-criminal death, also seems to be increasing,
despite their relatively low number overall. Cases in this group include those where an exact discrimination could not be made between intrinsic or extrinsic factors, or cases due to civil conflict, even if no criminal responsibility could be established. Furthermore, in most cases, bereaved family members strongly requested a death investigation to determine ‘‘the truth’’ behind the death. The reason for these kinds of autopsy being performed more frequently is unclear, but it may be because in recent years bereaved families have greater awareness of their rights to ask for their individual situation to be considered, which includes the right to request a death investigation. Whatever the reason, performing autopsy to adequately determine cause of death provides precise medical evidence to satisfy the bereaved family’s right to know the truth or to reveal the details of a civil conflict. These too are important roles of death investigations, alongside determining the presence or absence of criminal activity. On the other hand, because Japanese forensic autopsy is performed to determine possible criminal involvement based on the Code of Criminal Procedures, these kinds of autopsy have not been performed frequently enough, and it is often difficult to disclose information about autopsy results even when the autopsy seems to point to improbable criminal death or non-criminal death. Although the Act on Cause of Death Investigations and Identification of Bodies Handled by the Police was promulgated in 2013 to prevent criminal deaths from being overlooked, this new law also stipulates that consideration must be given to relieve the bereaved family’s anxiety and that valuable information obtained by autopsy should be actively passed on to the relevant administrative body as necessary. 4.3. Unchanged number of forensic autopsies in young people When comparing the age structure for forensic autopsies performed between 2003 and 2012, the number of autopsies in the >30s age group has increased markedly, while that in younger people (aged < 20 years) has remained at around only 20 autopsies per year. Although the ratio of young deaths to the total number of deaths is extremely low in the first place, the number of young deaths which would have been subject to a police investigation (e.g., suicide or unforeseen accident, excluding traffic accidents) is approximately 200 every year [6], which is not all that low. It is possible that these deaths included cases that should have been subjected to forensic investigation, including autopsy, to prevent a criminal death from being overlooked or to prevent a similar accident from occurring in the future, although these cases were not reviewed in detail in this study. Furthermore, even when a death is presumed to be natural, a precise diagnosis of sudden death in young people is crucial for understanding and preventing deaths due to disease, which are sometimes familial (e.g., hereditary arrhythmia). The decision on the cause of death and the judgment made on the need for autopsy should be performed in a careful manner, not only from the perspective of criminality, but also from a much broader one where death investigations are recommended for the benefit of bereaved families by providing them with a clear explanation of what happened. 4.4. Future of the Japanese death investigation system The results of this study suggest that the recent circumstances surrounding the death investigation system in Japan have made a notable difference to how forensic autopsy is being performed in one region, and that the number of forensic autopsies will continue to increase into the future in Chiba prefecture. Although our results may not be generalizable to the national situation, it is a fact that, similarly to Chiba prefecture, across the country the number of for-
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ensic autopsies is growing year on year without the number of obvious criminal death cases increasing. This suggests that other regions face a situation similar to ours, and further research should be conducted in other regions to verify this. It is inevitable that there the number of forensic autopsies performed will continue to increase if we are to prevent criminal death cases from being overlooked. Following a series of discussions based on the Act on the Promotion of Cause of Death Investigations promulgated in 2013, a new forensic institution is planned that will be responsible for multiagency death investigations, and this institution will need to handle an increasing number of autopsies in the future. To proceed with the discussion, similar research is necessary to identify detailed trends in forensic autopsy across the country. In areas without a medical examiner’s office, such as Chiba prefecture, referrals for autopsy typically occur only when criminality is suspected. However, the original purpose of death investigations is not only to avoid overlooking crimes, but also to flag public health issues (i.e., by preventing similar accidents or disease from reoccurring and alleviating bereaved families’ anxiety by providing appropriate explanations of the cause of death). As such, the death investigation system is designed to protect civil rights and preserve
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peace and order in society. While the death investigation system in Japan is being reformed, all those involved in death investigations should review the original purpose of the investigations and carry out more in-depth discussions as to when referrals for forensic autopsy are necessary. References [1] National Police Agency’s Report on the Fifth Committee for the Promotion of Cause of Death Investigations. Cabinet Office. Feb 2013. ; [accessed Jan. 2014]. [2] Modality of Cause of Death Investigation System that Prevents Overlooking Causes of Death by Criminal Acts. National Police Agency. Apr 2011. ; [accessed Jan. 2014]. [3] Tokyo Metropolitan Police Department arrested two men on alleged murder– suicide for insurance money. Yomiuri Shimbun, evening edition of Nov. 25, 2011, p. 13. [4] Unnatural death in Saitama: woman arrested on alleged murder–suicide of a man using coal briquettes, and another investigation in Chiba. Yomiuri Shimbun, evening edition of Feb. 1, 2010, p. 4 [5] Ishihara K. The enactment of two laws on cause of death investigations and the forensic autopsy system in Japan. Jpn Med J 2013;4649:27–30 (in Japanese). [6] Annual Public Health Statistics for Chiba prefecture. Chiba Prefecture. Jan. 2014 ; [accessed Jan. 2014].
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Trends in forensic autopsy in Chiba prefecture over the past decade Go Inokuchi ⇑, Kenji Ishihara, Mutsumi Hayakawa, Daisuke Yajima, Yohsuke Makino, Ayumi Motomura, Fumiko Chiba, Suguru Torimitsu, Hirotaro Iwase Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
a r t i c l e
i n f o
Article history: Received 17 March 2014 Received in revised form 9 May 2014 Accepted 1 June 2014 Available online 20 June 2014 Keywords: Forensic autopsy Medicolegal autopsy Death investigation Unusual death Unnatural death
a b s t r a c t The death investigation system in Japan is in the midst of a great transformation. As part of efforts to revise this system, in this study we analyzed the reasons the police refer unnatural death cases for forensic autopsy and, from an understanding of the trends of such referrals, we discuss the future direction of handling unnatural deaths in our country. For 1618 forensic autopsy cases handled by the First Investigation Division of Chiba Prefectural Police that were referred to our institution for forensic autopsy between 2003 and 2012, we tallied the number of autopsies by sex, age group, and reason for forensic autopsy for each year and investigated trends in the referrals over time. The results revealed that the number of autopsies increased annually from 2003 to 2012, with a marked increase from 2010. The number of autopsies increased particularly for cases of suspected criminal deaths, where it was unclear to the police before the forensic autopsy whether or not the death resulted from a criminal act. Our findings suggest that the number of forensic autopsies will continue to increase into the future in Chiba prefecture, and is a trend that is inevitable if we are to prevent criminal death cases from being overlooked. Although referrals for forensic autopsy in Japan are made only when criminal activity is suspected, the original purpose of death investigations is not only to avoid overlooking crimes, but also to flag public health issues. Therefore, together with the police, we need to review the original purpose and conduct more in-depth discussions about when referrals are necessary. Ó 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The death investigation system in Japan is in the midst of a great transformation. The inadequacy of the system and the very 1ow autopsy rate in our country have been pointed out since the early 2000s, and in 2007, the House of Representatives embarked on systemic reform. Very soon after, a case involving the death of a young sumo wrestler was deemed solely by the police, on the basis of an external examination of the body only, to be a natural death; no forensic autopsy was requested in what was later established to be a case of accidental perpetration of death. This socalled ‘‘Tokitsukaze sumo stable scandal’’ highlighted the need for systemic improvement of the country’s death investigation system, including the relevance and necessity of forensic autopsy in certain cases. In response to this situation, a Study Group on the Death Investigation System to Prevent Overlooking Causes of Death by Criminal Acts was set up by the National Police Agency in 2010, and two laws concerning the death investigation system ⇑ Corresponding author. Tel.: +81 43 226 2078; fax: +81 43 226 2079. E-mail address: [email protected] (G. Inokuchi). http://dx.doi.org/10.1016/j.legalmed.2014.06.001 1344-6223/Ó 2014 Elsevier Ireland Ltd. All rights reserved.
were enacted in 2012: the Act on Cause of Death Investigations and Identification of Bodies Handled by the Police and the Act on the Promotion of Cause of Death Investigations. Discussions have since been extended to cover the full spectrum of death investigation purposes, which include public health issues, by the Committee for the Promotion of Cause of Death Investigations set up by the Cabinet Office. Against this background, and given the fact that the police are handling more bodies [1], the number of forensic autopsies has been increasing annually, not only in Chiba prefecture but across Japan. As part of efforts to revise the death investigation system, we analyzed the reasons the police refer unnatural death cases for forensic autopsy and determined the trends of such referrals. From the trends identified, we discuss the future direction of handling unnatural deaths in our country. Japan’s death investigation system has two paths to medicolegal autopsy (Fig. 1): one is through forensic autopsy, which is based on criminal justice (Section 168 of the Code of Criminal Procedures) and is performed by departments of legal medicine at universities, the other path is through administrative autopsy or consent autopsy (requiring consent from the bereaved family),
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Fig. 1. Flow chart of Japan’s death investigation system, based on the number of bodies handled by the police and the autopsy rate for 2010 [2].
both of which are based on public health laws (Sections 8 and 7 of the Act Concerning Dissection and Preservation of a Dead Body). Administrative autopsy was introduced in large cities only, such as Tokyo, after World War II and is performed mainly by medical examiners. Consent autopsy is performed in those areas with no medical examiner’s office. As shown in Fig. 1, unusual deaths or reportable deaths are initially reported to the police, who then inspect the circumstances surrounding the death in each case and perform an external examination of the body to determine whether or not the death resulted from criminal activity. Reportable deaths are divided into the following three categories: criminal deaths, suspicious deaths (when it is unclear whether a death resulted from a criminal act), and non-criminal deaths. Based on the Code of Criminal Procedures, a forensic autopsy is requested in all criminal deaths, while in suspicious deaths, a specific postmortem investigation and an external body examination are conducted by a special police inspector if he or she deems necessary. This special police inspector has a role somewhat similar to that of a coroner or medical examiner in other countries but is not a medical doctor and is a member of the police force. The role of the special police inspector is not defined by law; however, it is generally recognized in Japan. These inspectors are selected from the First Investigation Division of Police and complete training in postmortem investigation including external examination. For deaths deemed non-suspicious or non-criminal by a special police inspector, an administrative autopsy or consent autopsy is performed in accordance with the Act Concerning Dissection and Preservation of a Dead Body when regarded as appropriate to do so. From April 2013, autopsies in accordance with the Act on Cause of Death Investigations and Identification of Bodies Handled by the Police were also started. An important point of note is that Japanese forensic autopsy is legally performed only when a special police inspector deems the death to be associated with criminal activity. For example, autopsy is rarely performed in the initial investigation when a case is judged as suicide. The decision of whether or not to perform a forensic autopsy is made solely by the special police inspector.
Several legal and social issues associated with Japan’s death investigation system have been identified. As shown in Fig. 1, the autopsy rate for unnatural/reportable deaths is extremely low in Japan. Moreover, administrative and consent autopsies are rarely performed. As mentioned above, forensic autopsy is performed only in cases judged to be associated with criminal activity in those areas without a medical examiner’s office such as Chiba prefecture. The majority of bodies, which are judged to result from non-criminal deaths in the initial police investigation, are processed without responsibly determining the cause of death: no medical or scientific evidence is collected and the cause is judged by external examination of the body only. It is in this context that cases of criminal or accidental perpetration of death have been overlooked in Japan’s death investigation system. Overlooked cases that have become apparent and have developed into a social issue in Japan [2] include those with no external findings, such as in cases of criminal intoxication, suffocation, accidental carbon monoxide intoxication due to faulty water heaters, and the Tokitsukaze sumo stable scandal mentioned above.
2. Materials and methods We investigated 1618 forensic autopsy cases handled by the First Investigation Division of Chiba Prefectural Police that were referred to our institution for forensic autopsy between 2003 and 2012. Cadavers handled by the Traffic Division of Chiba Prefectural Police, the Public Prosecutors Office, and the Coast Guard were excluded. Before conducting the autopsies, we obtained detailed case information from the police (i.e., name, sex, age, circumstances of death, background to the incident, mechanism of death, and reason for requesting a forensic autopsy) and recorded these information in the autopsy register. From this register, we tallied by year the number of autopsies by sex, age group, and reason for forensic autopsy and investigated trends in the referrals over time. It should be noted that some forensic autopsies handled by Chiba Prefectural Police are performed at institutions other than ours, but the number of bodies and autopsies used here to calculate the autopsy rate in Chiba prefecture includes these other cases.
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2.1. Classification by reason for forensic autopsy Although the need to perform a forensic autopsy had already been decided by a special police inspector, we sorted forensic cases into the following seven categories of reason for forensic autopsy after considering the contents described in the autopsy register (circumstances of death and situation leading to autopsy). 1. Obvious criminal death witnessed or confessed criminal death death due to injury obviously inflicted by another person (e.g., stab wound or ligature mark) 2. Suspicious death group 1 (strongly suspected criminal death) death with significant injury suggesting harm caused by another person based on external body or computed tomography findings death immediately after minor assault (i.e., the presence or absence of a correlation) death attributed to a person accused of a specific crime (e.g., professional negligence resulting in death or abandonment by a responsible person resulting in death) death suspected to involve a murder–suicide (not to be confused with double suicide) infant death (i.e., confirmation of a live birth, as opposed to a stillbirth) 3. Suspicious death group 2 (suspected criminal death or criminal death not ruled out) death due to unfortunate circumstances (e.g., history of illegal drug use, poor family relationships, or problematic associations), even if suicide or death due to self-negligence is suspected situation leading to death is unclear, even if injury or circumstances suggesting harm by another person are not detected reason for the autopsy is unclear from the standpoint of criminality based on the description in the autopsy register 4. Suspicious death group 3 (improbable criminal death or noncriminal death) consideration for or at the request of the bereaved family death with the need to distinguish between intrinsic and extrinsic factors for life insurance purposes (e.g., death in the bath or death due to a fall) death due to a possible civil conflict, even if no criminal responsibility can be established (e.g., a resident of a care facility died after staff looked away for a few seconds) 5. Unidentified death 6. Medically related death death during medical procedures suspected death due to malpractice death following discharge 7. Work-related death death while working death due to working environment factor (e.g., death in an explosion accident or by falling from a height)
Fig. 2. Number of forensic autopsies handled by the First Investigation Division of Chiba Prefectural Police at our institution.
Fig. 3. Change in the male-to-female ratio for forensic autopsy.
3.2. Change in the male-to-female ratio for the forensic autopsies conducted Fig. 3 shows that the male-to-female ratio during the investigation period changed little, at approximately 60:40, over the 10year period.
3.3. Change in age structure for the forensic autopsies conducted Fig. 4 shows the change in age structure for the forensic autopsies performed between 2003 and 2012. In 2012, the number of autopsies performed for the >30s age group increased markedly compared with that in 2003, while that for young people
3. Results 3.1. Change in the number of forensic autopsies conducted Fig. 2 shows the number of autopsies performed in Chiba prefecture increased annually from 2003 to 2012, with a marked increase evident from 2010. The rate of forensic autopsies for cases handled by the police in the prefecture was 2.7% in 2010 (8010 bodies handled by the police and 213 forensic autopsies performed) and 4.1% in 2012 (8153 and 336, respectively).
Fig. 4. Change in the number of autopsies performed between 2003 and 2012 according to age structure.
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(aged < 20 years) did not change significantly. The number of annual autopsies performed on young people was around 20 each year. 3.4. Trends in the autopsy rate according to reason for forensic autopsy Trends in the number of autopsies performed according to the reason for forensic autopsy are shown in Table 1 and Fig. 5. Over the 10-year period, the number of autopsies for suspicious death group 2 increased in all seven categories and, notably, the proportion of this group among all autopsies rose 2-fold, from 25.5% in 2003 (vs. 27.3% for obvious criminal deaths) to 51.2% (vs. 5.5% for obvious criminal deaths) in 2012. In this group, the number of autopsies due to suspected suicide by hanging, carbon monoxide poisoning from coal briquettes, or fire increased markedly from 2010 to 2012 (Fig. 6). The combined number of autopsies for the categories obvious criminal death and suspicious death group 1 showed no particular trends, with around 50–60 autopsies carried out each year. The number of autopsies for suspicious death group 3 and unidentified death showed an increasing trend. The number of autopsies for medically related death and work-related death showed no particular trends.
Fig. 5. Change in the number of autopsies for deaths categorized as obvious criminal death and suspicious death.
4. Discussion 4.1. Change in the number of forensic autopsies: an increased number of suspicious death group 2 cases According to a statement issued by the National Police Agency, the number of forensic autopsies has been increasing across Japan, especially since 2010 (6569 autopsies in 2009 vs. 8520 autopsies in 2012) [1]. This increasing trend coincides with an increase in the number of death scenes attended by special police inspectors which has occurred following attention given to overlooked criminal death cases. In this study, a similar tendency was recognized in Chiba prefecture. In the prefecture, a review of the reasons for forensic autopsies revealed that the number of suspicious death group 2 cases (suspected criminal death or criminal death not ruled out) has significantly increased, whereas the numbers of obvious criminal deaths and suspicious death group 1 cases (strongly suspected criminal death) were mostly unchanged. This indicates that most of the increased number of forensic autopsies constitutes suspicious deaths.
Fig. 6. Change in the number of autopsies for deaths due to suspected suicide by hanging, carbon monoxide poisoning by coal briquettes, and fire.
The specific reasons for requesting forensic autopsy in the suspicious death group 2 varied on a case-by-case basis. Most cases were referred for autopsy when criminal activity was suspected, even in the slightest, by the police or when the circumstances surrounding natural death, suicide, or self-negligence were unclear, as indicated by the classification group name. Looked at another way,
Table 1 Trends in the number of autopsies classified by reason for forensic autopsy. Reason for forensic autopsy
Obvious Criminal death Suspicious Death group 1 Suspicious Death group 2 Suspicious Death group 3 Unidentified Death Medically Related death Work-related Death Total
Year 2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
30 (27.3) 32 (29.1) 28 (25.5) 0 (0) 11 (10) 9 (8.2) 0 (0) 110
19 (17.0) 24 (21.4) 30 (26.8) 1 (0.9) 26 (23.2) 7 (6.3) 5 (4.5) 112
26 (19.8) 17 (13.0) 41 (31.3) 5 (3.8) 23 (17.6) 19 (14.5) 0 (0) 131
18 (12.9) 29 (20.9) 28 (20.1) 7 (5.0) 43 (30.9) 11 (7.9) 3 (2.2) 139
25 (18.5) 19 (14.1) 47 (34.8) 5 (3.7) 27 (20.0) 8 (5.9) 4 (3.0) 135
28 (17.9) 21 (13.5) 54 (34.6) 2 (1.3) 32 (20.5) 13 (8.3) 6 (3.8) 156
31 (20.0) 21 (13.5) 45 (29.0) 8 (5.2) 37 (23.9) 9 (5.8) 4 (2.6) 155
20 (10.9) 31 (16.8) 74 (40.2) 13 (7.1) 33 (17.9) 9 (4.9) 4 (2.2) 184
26 (12.7) 34 (16.7) 74 (36.3) 11 (5.4) 50 (24.5) 8 (3.9) 1 (0.5) 204
16 (5.5) 47 (16.3) 148 (51.2) 16 (5.5) 39 (13.5) 15 (5.2) 8 (2.8) 289
Numbers in parentheses indicate the percentage of autopsies in each category relative to total autopsies (%) in each year.
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this finding suggests that a number of these deaths may have been previously judged as non-criminal deaths in the initial police investigation and were thus not referred for forensic autopsy. According to an official announcement made by the police, 43 cases of criminal death have been overlooked in Japan since 1998 [2]. In half of these cases the cause of death was incorrectly determined as not being related to criminal activity in the initial investigation. Therefore, it would seem that the increased number of suspicious death group 2 cases was the result of spreading awareness that, first, more accurate judgments can be made and, second, the overlooking of criminal cases can be avoided by performing detailed forensic investigations such as autopsy and toxicology. In Chiba prefecture, a case of murder disguised as suicide by hanging was exposed in 2011 [3]. It was initially judged as a non-criminal death (suicide) in the initial investigation by the police and no autopsy was performed. In addition, in several prefectures, the modus operandi of murder disguised as suicide by carbon monoxide poisoning from coal briquettes, which made the headlines in 2010 as a series of murders by a marriage swindler to exploit insurance money [4], was revealed after more than one victim was found. In a detailed review of the suspicious death group 2 category, there was a clear increase in the number of suspected suicide deaths by hanging, coal briquettes, or fire for 2010 and 2012, an increase which undoubtedly reflects the attention drawn by these high-profile overlooked criminal cases. The remaining half of the overlooked criminal death cases announced by the police resulted from their insufficient initial investigations (e.g., inquiries into insurance matters were not made, toxicological tests were not performed, or insufficient corroborating evidence was collected), even though the actual causes of death had been correctly established. Murder disguised as suicide by hanging or poisoning by coal briquettes fall into this category. The very existence of this category suggests that the initial investigation by the police, along with determining the correct cause of death, is critical to ensuring that criminal deaths are not overlooked. The purpose of forensic investigations, including autopsy, in these kinds of cases is also to preserve evidence for court proceedings and to determine the correct cause of death. Therefore, it appears that the increasing number of suspicious death group 2 cases reflects the decision of the special police inspector, who requests autopsy, to preserve the evidence and take precautions against not overlooking possible criminal involvement. From the standpoint of preventing overlooked criminal deaths in Chiba prefecture, our findings indicate that the autopsy rate is continuing to rise alongside the increasing number of suspicious death group 2 cases. However, the autopsy rate for reportable deaths is still low compared with that at forensic institutions in other developed countries (e.g., 89.1% in Sweden, 53.3% in Victoria, Australia, 19.3% in Hamburg, Germany) or in Akita prefecture, which has the highest autopsy rate in Japan at 13.8% [2]. The classification used in this study (criminal death, suspicious death, and non-criminal death), which is based on the specific death investigation system in Japan, may appear strange to some because it is possible in this system for unnatural deaths to be classified as non-criminal deaths purely on the basis of an external body examination without a detailed forensic investigation including autopsy [5]. Given the above, the concept of Japan’s death investigation system defined by the Code of Criminal Procedures needs to be reconsidered. 4.2. Increased number of unnatural death group 3 cases In Japan, forensic autopsy is basically required only when criminality is suspected. However, the number of suspicious death group 3 cases, which are judged by the police as improbable criminal death or non-criminal death, also seems to be increasing,
despite their relatively low number overall. Cases in this group include those where an exact discrimination could not be made between intrinsic or extrinsic factors, or cases due to civil conflict, even if no criminal responsibility could be established. Furthermore, in most cases, bereaved family members strongly requested a death investigation to determine ‘‘the truth’’ behind the death. The reason for these kinds of autopsy being performed more frequently is unclear, but it may be because in recent years bereaved families have greater awareness of their rights to ask for their individual situation to be considered, which includes the right to request a death investigation. Whatever the reason, performing autopsy to adequately determine cause of death provides precise medical evidence to satisfy the bereaved family’s right to know the truth or to reveal the details of a civil conflict. These too are important roles of death investigations, alongside determining the presence or absence of criminal activity. On the other hand, because Japanese forensic autopsy is performed to determine possible criminal involvement based on the Code of Criminal Procedures, these kinds of autopsy have not been performed frequently enough, and it is often difficult to disclose information about autopsy results even when the autopsy seems to point to improbable criminal death or non-criminal death. Although the Act on Cause of Death Investigations and Identification of Bodies Handled by the Police was promulgated in 2013 to prevent criminal deaths from being overlooked, this new law also stipulates that consideration must be given to relieve the bereaved family’s anxiety and that valuable information obtained by autopsy should be actively passed on to the relevant administrative body as necessary. 4.3. Unchanged number of forensic autopsies in young people When comparing the age structure for forensic autopsies performed between 2003 and 2012, the number of autopsies in the >30s age group has increased markedly, while that in younger people (aged < 20 years) has remained at around only 20 autopsies per year. Although the ratio of young deaths to the total number of deaths is extremely low in the first place, the number of young deaths which would have been subject to a police investigation (e.g., suicide or unforeseen accident, excluding traffic accidents) is approximately 200 every year [6], which is not all that low. It is possible that these deaths included cases that should have been subjected to forensic investigation, including autopsy, to prevent a criminal death from being overlooked or to prevent a similar accident from occurring in the future, although these cases were not reviewed in detail in this study. Furthermore, even when a death is presumed to be natural, a precise diagnosis of sudden death in young people is crucial for understanding and preventing deaths due to disease, which are sometimes familial (e.g., hereditary arrhythmia). The decision on the cause of death and the judgment made on the need for autopsy should be performed in a careful manner, not only from the perspective of criminality, but also from a much broader one where death investigations are recommended for the benefit of bereaved families by providing them with a clear explanation of what happened. 4.4. Future of the Japanese death investigation system The results of this study suggest that the recent circumstances surrounding the death investigation system in Japan have made a notable difference to how forensic autopsy is being performed in one region, and that the number of forensic autopsies will continue to increase into the future in Chiba prefecture. Although our results may not be generalizable to the national situation, it is a fact that, similarly to Chiba prefecture, across the country the number of for-
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ensic autopsies is growing year on year without the number of obvious criminal death cases increasing. This suggests that other regions face a situation similar to ours, and further research should be conducted in other regions to verify this. It is inevitable that there the number of forensic autopsies performed will continue to increase if we are to prevent criminal death cases from being overlooked. Following a series of discussions based on the Act on the Promotion of Cause of Death Investigations promulgated in 2013, a new forensic institution is planned that will be responsible for multiagency death investigations, and this institution will need to handle an increasing number of autopsies in the future. To proceed with the discussion, similar research is necessary to identify detailed trends in forensic autopsy across the country. In areas without a medical examiner’s office, such as Chiba prefecture, referrals for autopsy typically occur only when criminality is suspected. However, the original purpose of death investigations is not only to avoid overlooking crimes, but also to flag public health issues (i.e., by preventing similar accidents or disease from reoccurring and alleviating bereaved families’ anxiety by providing appropriate explanations of the cause of death). As such, the death investigation system is designed to protect civil rights and preserve
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peace and order in society. While the death investigation system in Japan is being reformed, all those involved in death investigations should review the original purpose of the investigations and carry out more in-depth discussions as to when referrals for forensic autopsy are necessary. References [1] National Police Agency’s Report on the Fifth Committee for the Promotion of Cause of Death Investigations. Cabinet Office. Feb 2013. ; [accessed Jan. 2014]. [2] Modality of Cause of Death Investigation System that Prevents Overlooking Causes of Death by Criminal Acts. National Police Agency. Apr 2011. ; [accessed Jan. 2014]. [3] Tokyo Metropolitan Police Department arrested two men on alleged murder– suicide for insurance money. Yomiuri Shimbun, evening edition of Nov. 25, 2011, p. 13. [4] Unnatural death in Saitama: woman arrested on alleged murder–suicide of a man using coal briquettes, and another investigation in Chiba. Yomiuri Shimbun, evening edition of Feb. 1, 2010, p. 4 [5] Ishihara K. The enactment of two laws on cause of death investigations and the forensic autopsy system in Japan. Jpn Med J 2013;4649:27–30 (in Japanese). [6] Annual Public Health Statistics for Chiba prefecture. Chiba Prefecture. Jan. 2014 ; [accessed Jan. 2014].
