Writing the Necropsy Report

Abstract

To be of use, the findings of the forensic necropsy must be communicated using clear and concise language that can be understood by judges, lawyers, jurors, and other interested parties who likely will have little or no training in science. The report must be generated in a timely manner before details fade from memory. The organization of the report can vary widely but should include separate sections on demographic data as well as results of the external and internal exam, histopathology findings, and ancillary tests. A summary opinion that clearly outlines the cause, manner, and mechanism of death will help convey the significance of the findings to the court as it tries to understand the circumstance around the death of an animal, determine if a crime was committed, and determine an appropriate resolution to the case.

Appendices

Appendix 1: Cornell University Forensic Necropsy Report Form

Date:

Time:

Location:

The necropsy was authorized by

Indicate the name of the individual or agency that authorized the necropsy. The authorizing agent is the only one who receives a copy of the results. All other requests for copies of the report should only be honored if accompanied by a subpoena.

The purpose of the examination is to establish, if possible, the cause of death.

The purpose of the examination is modified based on questions that the submitting agency would like answered. For example, the degree of pain and suffering, chronicity of wounds, etc.

The standard Cornell University method of necropsy is performed, with the body in left lateral recumbency and the organs removed en masse, including the pluck, gastrointestinal tract, genitourinary system, eyes, and brain.

For small animals, reference Necropsy Guide for Dogs, Cats, and Small Animals, First Edition. Edited by Sean P. McDonough and Teresa Southard. John Wiley & Sons, Inc, 2017.

For large animals, reference The Necropsy Book, Fourth Edition. Edited by John M. King, Lois Roth-Johnson, David C. Dodd and Marion E. Newson. Charles Louis Davis, DVM Foundation, 2005.

Those in attendance and their role

• Pathologist-in-charge:

• Assistant:

• Observer/representative:

Gross Description:

• 1. Presentation

  • (a) How the body was protected (e.g., plastic bag) and stored prior to necropsy (e.g., refrigerated, frozen, etc.):

  • (b) Carcass weight:

  • (c) Items accompanying the body (blankets, food bowls, toys):

• 2. Postmortem changes

  • (a) Postmortem interval (indicate if estimated):

  • (b) Rigor mortis

  • (c) Livor mortis:

  • (d) Degree of corneal clouding and collapse:

  • (e) Discolorations:

  • (f) Drying of the tongue:

  • (g) Other (skin slippage, loss of hair, insects, etc.):

• 3. External exam

  The body is documented with at least five pictures: dorsum, ventrum, left side, right side, and face

• (a) Identifying features

  • i. Species:

  • ii. Breed:

  • iii. Sex:

  • iv. Coat color:

  • v. Age (indicate if estimated):

  • vi. Special markings/tattoos:

  • vii. Scanned for microchip (Y/N)

(If a microchip is found, record the ID number and save as evidence)

• (b) Body condition score (indicate scale) or general condition:

• (c) Items on the body (collars, harnesses, etc.):

• (d) Evidence of medical intervention (intravenous catheters, bandages, etc.):

• (e) Hair coat

  • i. General quality:

  • ii. Abnormalities/lesions (alopecia, ectoparasites, etc.):

• (f) External exam findings by body region (note WNL if within normal limits or NE if not examined):

  • i. Head and neck:

  • ii. Thorax:

  • iii. Abdomen:

  • iv. Thoracic limbs, including nails/hooves:

  • v. Pelvic limbs, including nails/hooves:

  • vi. Genitalia, perineum, and tail:

• 4. Internal exam (note WNL if within normal limits or NE if not examined):

  • (a) Integument (including mammary glands):

  • (b) Head

    • i. Subcuticular surface of scalp:

    • ii. Skull:

    • iii. Brain and meninges:

    • iv. Nasal cavity/nasal sinuses:

    • v. Atlanto-occipital junction:

    • vi. Pinnae:

    • vii. External ear canal:

    • viii. Middle and inner ears:

  • (c) Neck and pharynx

    • i. Oral cavity (teeth and gums, hard and soft palate):

    • ii. Tongue:

    • iii. Pharynx:

    • iv. Larynx, hyoid apparatus, and trachea:

    • v. Neck vessels and strap muscles:

  • (d) Thoracic wall and pleural space:

  • (e) Abdominal wall and peritoneal space:

  • (f) Vertebral column and spinal cord:

  • (g) Cardiovascular system:

  • (h) Respiratory system:

  • (i) Digestive system:

  • (j) Hepatobiliary system and pancreas:

  • (k) Reticuloendothelial system:

  • (l) Urogenital system:

  • (m) Endocrine system:

  • (n) Musculoskeletal system:

    • i. Joints opened:

  • (o) Additional dissection (Placenta, etc.):

• 5. Evidence of trauma:

  Since projectiles often pass through multiple organs and body regions, it is best to describe them in a single, coherent manner rather than separating the projectile path across multiple sections of the report. In the event of multiple wounds, each should be numbered and referred to by number in the report. Diagrams showing the location of entrance and exit wounds are also useful.

10.1.1 Ancillary Procedures and Laboratory Tests:

Histologic Description:

• 1. Block Listing

• 2. List slide number and tissues.

Significant changes were found in the following tissues:

10.1.2 Pathologic Diagnoses

10.1.3 Cause of Death:

To a reasonable degree of medical certainty, the primary cause of death is …..

List the primary (proximate/underlying) cause of death first, and then list the immediate cause of death (e.g., euthanasia). The primary (underlying, proximate) cause of death is the etiologically specific first, earliest injury or disease that set in motion the sequence of events that led to death (if not for X, the animal would still be alive). Cardiopulmonary arrest is NEVER the underlying cause of death (heart and lungs fail in all animals that die). The immediate cause of death is the last, final, etiologically specific injury or disease, different from but the consequence of the underlying cause of death. This includes euthanasia.

10.1.4 Opinion

Appendix 2

Used with permission by Dr. Melinda Merck

Appendix 3

Used with permission by Dr. Melinda Merck