The Evolution of Postmortem Investigation: A Historical Perspective on Autopsy’s Decline and Imaging’s Role in its Revival

Nadia Solomon ^1,2,3* Dominic Gascho ⁴ Natalie L Adolphi ⁵ Laura Filograna ⁶ Harold Sanchez ⁷ James R Gill ⁸ Jamie Elifritz ^5,9

• ¹ Department of Radiology and Biomedical Imaging, School of Medicine, Yale University, New Haven, Connecticut, United States
• ² Investigative Medicine Program, Yale Graduate School of Arts and Sciences, Yale University, New Haven, United States
• ³ New York City Office of Chief Medical Examiner, New York, United States
• ⁴ Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
• ⁵ Center for Forensic Imaging, Office of the Medical Investigator, University of New Mexico, Albuquerque, United States
• ⁶ Integrated Care Processes Department, UOC of Diagnostic Imaging, University of Rome, Rome, Italy
• ⁷ Department of Pathology, School of Medicine, Yale University, New Haven, Connecticut, United States
• ⁸ Connecticut Office of the Chief Medical Examiner, Farmington, United States
• ⁹ The Forensic Radiology Group, Anderson, United States

Autopsy is generally regarded as the gold standard for cause of death determination, the most accurate contributor to mortality data. Despite this, autopsy rates have substantially declined, and death certificates are more frequently completed by clinicians. Substantial discrepancies between clinician-presumed and autopsy-determined cause of death impact quality control in hospitals, accuracy of mortality data, and, subsequently, the applicability and effectiveness of public health efforts. This problem is compounded by wavering support for the practice of autopsy by accrediting bodies and academic bodies governing pathology specialty training. In forensic settings, critical workforce shortages combined with increased workloads further threaten sustainability of the practice.Postmortem imaging (PMI) can help mitigate these ongoing problems. Postmortem computed tomography can help clarify manner and cause of death in a variety of situations and has undeniable advantages, including cost reduction, the potential to review data, expedient reporting, archived unaltered enduring evidence (available for expert opinion, further review, demonstrative aids, and education), and (when feasible) adherence to cultural and religious objections to autopsy. Integration of radiology and pathology is driving a transformative shift in medicolegal death investigations, enabling innovative approaches that enhance diagnostic accuracy, expedite results, and improve public health outcomes. This synergy addresses declining autopsy rates, the forensic pathologist shortage, and the need for efficient diagnostic tools. By combining advanced imaging techniques with traditional pathology, this collaboration elevates the quality of examinations and advances public health, vital statistics, and compassionate care, positioning radiology and pathology as pivotal partners in shaping the future of death investigations.