What should be in a Postmortem Report- Model form

Medicolegal cases (MLC) are an integral part of medical practice that is frequently encountered by Medical Officers (MO). The occurrence of MLCs is on the increase, both in the Civil as well as in the Armed Forces. Proper handling and accurate documentation of these cases is of prime importance to avoid legal complications and to ensure that the Next of Kin (NOK) receive the entitled benefits.

advtanmoy 03/10/2020 4 minutes read

MODEL POST-MORTEM REPORT FORM

NAME OF INSTITUTION ____________________________________________
Post Mortem Report No. ____________________ Date ___________________
Conducted by Dr. ______________________________________________________
Date & Time of receipt of the body
and Inquest papers for Autopsy __________________________________________
Date & Time of commencement of Autopsy _______________________________
Time of completion of Autopsy___________________________________________
Date & Time of examination of the dead body
at Inquest (as per Inquest Report) ________________________________________
Name & Address of the person __________________________________________
video recording the Autopsy ______________________________________________

Note: The tape should be duly sealed, signed and dated and sent to the National
Human Rights Commission, Sardar Patel Bhawan, Sansad Marg, New Delhi.
_____________________________________________________________________

CASE PARTICULARS

1- (a) Name of deceased and as entered
in the Jail or Police record_______________________________________
(b) S/O, D/O, W/O ________________________________________________
(c) Address : ______________________________________________________

2. Age (Approx) :___________ yrs; Sex : Male/Female

3. Body brought by (Name and rank of Police officials)
(i) ___________________________________________________

(ii) ___________________________________________________
of Police Station _______________________________________
4. Identified by (Names & addresses of relatives/persons acquainted )
(i) _____________________________________________________________
(ii) _____________________________________________________________
IF HOSPITAL DEAD BODIES – (particulars as per hospital records)
Date & Time of Admission in Hospital ________________________________
Date & Time of Death in Hospital ____________________________________
Central Registration No. of Hospital _______________________________

SCHEDULE OF OBSERVATIONS
(A) GENERAL
(l) Height _______ cms. (2) Weight _______________ Kgs.
(3) Physique – (a) lean/ medium / obese
(b) Well built/average built/poor built/emaciated
(4) Identification features (if body is unidentified)
(i) __________________________________________
(ii) ___________________________________________
(iii) Finger prints be taken on seperate sheet and attached by the doctor.
(5) Description of clothes worn – important features:
(6) Post-mortem Changes :
(a) As seen during inquest
– Whether rigor mortis present _______________________________________
– Temperature (Rectal) ____________________________________________
– Others ________________________________________________________
(b) As seen at Autopsy –

(7) (a) External general appearance –
(b) State of eyes
(c) Natural orifices

(B) EXTERNAL INJURIES:
(Mention Type, Shape, Length x Breadth & Depth of each injury and its relation
to important body landmark. Indicate which injuries are fresh and which are old
and their duration.)
______________________________________________________________________

Instructions :-

(i) Injuries be given serial number and mark similarly on the diagrams attached.

(ii) In stab injuries, mention angles, margins and direction inside body.

(iii) In fire arm injuries, mention about effects of fire also.

C) INTERNAL EXAMINATION

1- HEAD

(a) Scalp findings
(b) Skull (Describe fractures here & show them on body diagram enclosed)
(c) Meninges, meningeal spaces & Cerebral vessels
(Hemorrhage & its locations, abnormal smell etc. be noted)
(d) Brain findings & Wt. (Wt. _____________________ gms.)
(e) Orbital, nasal & aural cavities – findings.

2. NECK
– Mouth, Tongue & Pharynx
– Larynx & Vocal cords
– Condition of neck tissues
– Thyroid & other cartilage conditions
– Trachea

3. CHEST
– Ribs and Chest wall
– Oesophagus
– Trachea & Bronchial Tree
– Pleural Cavities – R – – L –
Lungs findings & Wt. – Rt. ___________ gms. & Lt. _____________ gms.
– Pericardial Sac
– Heart findings & Wt. ________ .
– Large blood vessels

4. Abdomen
– Condition of abdominal wall
– Peritoneum & Peritoneal cavity
– Stomach (wall condition, contents & smell) (Weight ______________ gms.)
– Small intestines including appendix
– Large intestines & Mesentric vessels
– Liver including
gall bladder (wt. _________________ gms)
– Spleen (wt. ___________ gms.)
– Pancreas
– Kidneys finding & Wt. – Rt. ______ gms. & Lt. _________ gms.
– Bladder & urethra
– Pelvic cavity tissues
– Pelvic Bones
– Genital organs (Note the condition of vagina, scrotum, presence of foreign body, presence of foetus, semen or any other fluid, and contusion, abrasion in and around genital organs).

5. SPINAL COLUMN & SPINAL CORD (To be opened where indicated)

OPINION

i) Probable time since death (keep all factors including observations at inquest)

ii) Cause & manner of death- The cause of death to the best of my knowledge and belief is :-
(a) Immediate cause –
(b) Due to –
(c) Which of the injuries are ante-mortem/post-mortem and duration if antemortem?
(d) Manner of causation of injuries
(e) Whether injuries (individually or collectively) are sufficient to cause death in
ordinary course of nature or not ?

iii) Any other

SPECIMENS COLLECTED & HANDED OVER (Please tick)

a) Viscera (Stomach with contents, small intestine with contents, sample of liver, kidney (one half of each), spleen, sample of blood on gauze piece (dried), any other viscera, preservative used)
b) Clothes
c) Photographs (Video cassettes in case of custody deaths), finger prints etc)
d) Foreign body (like bullet, ligature etc.)
e) Sample of preservative in cases of posioning.
f) Sample of seal
g) lnquest papers (mention total number & initial them)
h) Slides from vagina, semen or any other material

PM report in original, ____inquest papers, dead body, clothings and other articles
(mention there) duly sealed (Nos. ___ ) handed over to police official ______________
No. ________________ of PS ____________________ whose signatures are herewith.

Signature : ___________________________

Name of Medical Officer _______________
(in block letters) _____________________
Designation _________________________

SEAL