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The autopsy report and the negative autopsy

  • Procedure

The autopsy report describes what was found and interprets it, so that another expert could reach their own conclusions; sometimes the cause stays unknown.

Updated

What it is

The autopsy report is the written record of the medico-legal autopsy. According to the UN Minnesota Protocol it must be complete enough for another expert, at another time and with the photographs, to have every observation needed to reach their own conclusions. It does not stop at a list of findings: it interprets them, saying how each injury was probably caused, whether it caused or contributed to death, and attributing each finding to injury, medical treatment, disease or postmortem change. It ends with the cause of death in the WHO format and, where the law asks it, the manner of death. A 'negative autopsy' is one in which, after a complete autopsy and all tests, no cause is found; it is reported as undetermined, and in young people it may point to an inherited heart rhythm disorder. The general rules of the expert report (what it contains, when it is handed over, the oral testimony) are on the expert report page.

What to document

  • The questions asked and an answer to each one.
  • Findings and interpretation kept apart.
  • Pending tests and how they could change the conclusions.
  • Deviations from the usual technique and their reasons (for example, decomposition or limited time).
  • The degree of certainty of each conclusion.
  • In a negative autopsy: what was done to rule out each cause and which samples are kept.

How it is done

  1. Identify the case: authority that asked, questions asked, identity of the body and how it was established.
  2. Summarise the history and the scene information received, citing where each piece came from.
  3. Describe the external and internal findings in order, with measurements, and list photographs and imaging.
  4. List the samples taken and the results received; say which results are still pending.
  5. Interpret: how each injury was caused, whether it is vital, how it relates to death, and other diseases present.
  6. State the cause of death in the WHO format and, if asked, the manner of death.
  7. Answer each question of the authority; say clearly which cannot be answered on a scientific basis and why.
  8. Sign, date and hand the report to the authority; keep a copy and the photographs in the file.

Next step: what to do and document

  • Write in clear language that a judge can follow; explain technical terms.
  • Do not fill gaps: if the cause is not known after all tests, write 'undetermined' rather than a guess.
  • Issue a provisional report if needed and a final one when results arrive, stating the change.
  • In unexplained sudden death in a young person, keep a blood or tissue sample for genetic study and recommend heart screening of relatives.
  • Remember that the objectives of the medico-legal autopsy include cause, manner, time of death and identification (Decreto 786 de 1990, art. 5).
  • Official text checked on 2026-11-13 at funcionpublica.gov.co.

Common mistakes

  • Giving 'cardiorespiratory arrest' or 'multiple organ failure' as the cause of death.
  • Mixing findings with opinions in the same paragraph.
  • Writing a definite cause when the evidence only allows 'consistent with'.
  • Closing a negative autopsy without toxicology and histology.
  • Not mentioning injuries caused by resuscitation, which the defence may later present as assault.

Test yourself

Think of the answer, then tap the question to see it.

What standard should an autopsy report meet according to the Minnesota Protocol?

It must be complete enough for another forensic doctor, with the photographs, to reach their own conclusions about the death.

Why is 'cardiorespiratory arrest' not an acceptable cause of death?

Because it is the mode or final mechanism common to all deaths, not the disease or injury that started the chain.

What is a negative autopsy and how is it reported?

An autopsy in which, after complete examination, histology and toxicology, no cause is found; the cause is reported as undetermined.

What should be done in an unexplained sudden death in a young person with a negative autopsy?

Keep a sample for genetic testing (molecular autopsy), since an inherited rhythm disorder may be the cause, and recommend screening of relatives.

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Educational content on forensic and legal medicine; not legal advice and no substitute for the technical guides of Colombia's National Institute of Legal Medicine and Forensic Sciences. Laws change: each page links the official text and says when it was last checked. For a real case, follow the guide in force and ask the competent authority.

Sources: The Minnesota Protocol on the Investigation of Potentially Unlawful Death (2016) (Office of the United Nations High Commissioner for Human Rights, 2017); Molecular autopsy in sudden cardiac death (Global Cardiology Science and Practice (Campuzano O, Sarquella-Brugada G), 2023); Decreto 786 de 1990: autopsias clínicas y médico-legales y viscerotomías (compilado en el Decreto 780 de 2016) (Función Pública, Gestor Normativo, 1990).

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