Demystifying Forensic Medicine: Tales from the Morgue

Join us on the Analytical Zen Podcast  for an interview with Professor Christopher Milroy, a forensic pathologist and professor based in Ottawa, Canada.

Professor Milroy earned his medical degree from the University of Liverpool and trained in pathology in Liverpool, Bristol and London before specializing in forensic pathology in Sheffield. From 1990 to 2008, he worked as a forensic pathologist and professor of forensic pathology in Sheffield, before moving to Ottawa in 2008.

In addition to his medical qualifications, Professor Milroy holds two law degrees from the University of London. He is a fellow of the Royal College of Pathologists, the Royal College of Physicians of Canada and the Faculty of Forensic and Legal Medicine. Throughout his career, he has performed thousands of autopsies and served as an expert witness in hundreds of murder trials across multiple countries. He has also provided expert testimony in public inquiries in both Canada and Ireland.

Professor Milroy's research interests include homicide, suicides, drug-related deaths, post-mortem toxicology, biochemistry and the history of forensic medicine. In 2023, he was honoured with the title of Officer of the Order of the British Empire (OBE) in the King’s Birthday Honours.

Join the conversation at The Analytical Zen Podcast! Reach out to us via email at theanalyticalzenpodcast@gmail.com.

The opinions expressed  by the guests are their own and do not necessarily reflect the views of The Analytical Zen Podcast.

Transcript

Geraldine 0:11

Welcome to the Analytical Zen Podcast, where we delve into the minds of leading scientists and professionals exploring forensics, toxicology, medicine and health in terms of mind, body and spirit. I'm your host, geraldine M Dowling. What should you expect in the Analytical Zen podcast? Well, we'll dive into cutting edge research and topics that inspire curiosity, the latest in forensic and clinical toxicology pursuits, and engage in conversations and perspectives from disciplines outside of these fields.

Geraldine 0:47

Today, we welcome Chris Milroy, who is a forensic pathologist and professor based in Ottawa in Canada. He qualified in medicine from the University of Liverpool and trained in pathology in Liverpool, Bristol and London before training in forensic pathology in Sheffield. He was a forensic pathologist in Sheffield from 1990 to 2008, where he was a professor of forensic pathology. In 2008, he moved to Ottawa, canada. As well as his medical qualifications, he has two law degrees from the University of London. He's a fellow of the Royal College of Pathologists, the Royal College of Physicians of Canada and the Faculty of Forensic and Legal Medicine. He's performed thousands of autopsies and has appeared as an expert witness in hundreds of murder trials in many countries. He's been an expert witness in public inquiries in Canada and Ireland. His research interests have included murder, suicides, drug-related deaths, porous morton, biochemistry and the history of forensic medicine. In 2023, he was made an officer of the order of the British Empire. In the King's Birthday Honours, I'd like to welcome Professor Chris Mulroy to the Analytical Zen podcast.

Chris 2:14

Thank you.

Speaker 3 2:16

Chris, can you tell us a little bit about your background and how you became interested in forensic pathology?

Chris 2:25

and how you became interested in forensic pathology. So forensic pathology is really not seen much now in the undergraduate medical curriculum. But at Liverpool we had the option of doing some short electives as well as a longer elective. I'd already decided that for my longer elective I was going to go to India, which I did, but for the shorter one I decided to do forensic pathology, and so there was a lovely man who was the forensic pathologist then in Liverpool, jim Burns, and so I spent two weeks with him and I thought that it was very interesting. And so I spent two weeks with him and I thought that it was very interesting. I liked ordinary pathology, and so that was really when I decided to pursue a career as a forensic pathologist.

Geraldine 3:16

And luckily it worked out. What training and education are required.

Chris 3:18

So forensic pathologists are all physicians and so you have to go to medical school, unlike other forensic science disciplines that you have to get um bscs and phds, for medicine you've got to get your medical degree. Then, um, in the english-speaking world, you train uh in basically hospital pathology, so you're learning about disease and then at the end of that training period and typically having done exams in it so that's where my fellowship of the royal college of pathologists is based uh, you do extra training in forensic pathology, which I did in sheffield, and um you come out about 14 years after you go into medical school as a new forensic pathologist. So it's quite a long training.

Geraldine 4:15

Chris, how does your role differ from that of a medical examiner or a coroner?

Chris 4:29

so the medical examiner and the coroner are two types of practitioner that works in medical legal death investigations. The coroner is the more traditional, possibly well-known role and, depending on where you are, a coroner may be a doctor, it may be a lawyer, it may be a lawyer or it could be a layperson. So in Canada we have laypeople who are coroners, we have doctors who are coroners and we have lawyers who are coroners, depending on which system you're in. I am a coroner in Ontario, but I don't typically work as a coroner. I don't typically work as a coroner In our system.

Chris 5:04

Coroners do the investigations and then, if they need a post-mortem examination or autopsy, they request that we do it under a warrant and they then conduct inquests.

Chris 5:20

In our system we don't do many inquests, whereas, for example, in England and Ireland you have't do many inquests, whereas, for example, in England and Ireland you have a lot more inquests. And then medical examiners are a more modern system where you have the forensic pathologist in charge of the medical legal death investigation, so they're effectively the coroner and the forensic pathologist combined. And in North America, where medical examiner systems exist in Canada we have four out of the ten provinces and then we have three territories which are coroner systems. In the United States about half of the population is served by medical examiners, and so there are big offices in places like New York, Los Angeles, Dallas, San Antonio, St Louis and so on. So, essentially, medical examiners are forensic pathologists. Not all, very few coroners are I put it in those in that way, but in all of the systems forensic pathology is the academic discipline at the center of the death investigation, and we're the people that conduct post-mortem examinations.

Geraldine 6:48

How do you handle the emotional challenges of working with death and trauma on a daily basis?

Chris 6:55

I think that people may be surprised that it really doesn't really affect us too much. Obviously, we're trained as doctors. Really affect us too much? Obviously, we're trained as doctors and in medicine one of the things we have to deal with is people who are dying or having curable diseases and they will die. We also have our personal experiences and the role that we have in conducting a post-mortem examination of somebody is to do the best we can for that person in establishing why they died. And you know, a lot of forensic pathologists will tell you oh, I would like so-and-so to do my autopsy, because they will do a good job. And I mean, there's nothing new about this.

Chris 7:51

The philosopher jeremy bentham had himself autopsied in the 1830s, um, and I think that therefore, we separate the emotion of the death from our physical work. And people say to me well, what about children? And the irony is that the more injured and hurt a child is, in one sense, the easier our job is, because we don't face the controversies of not being able to find a cause of death, which is one of the things that we have to deal with. And I found it more difficult to come to terms with the fact that many of the post-mortem examinations in what are often called cot or crib deaths. We didn't have an answer and that was almost more distressing than the actual process of autopsying the child. And of course, it's absolutely devastating for the parents to have this.

Chris 8:52

Some of the cases a minority die of inflicted injury from the parents and, as I say, those are often the easier ones to deal with because if the cause of death is obvious and there's a lot of injuries, then our evidence cannot be challenged and we have the knowledge that we've been able to find a cause of death.

Chris 9:17

But if we don't have a cause of death, that took some getting used to and in a proportion of the cases we do, both in adults and children, we won't find a cause of death. Now, some of those are because the body's decomposed. That's fine. We fully understand that If you find someone that's been missing over a winter and their body's completely decomposed, that's, you know, no one's going to find the cause of death, no one's going to find the cause of death. But in others, you know the marathon runner that drops dead and we just don't find anything. I mean, we now understand a lot more about why these people die. They often have genetic abnormalities of their heart conduction and we're able to test for that now in a way we weren't 30 years ago. So we do make progress in all of these and that's quite satisfying to be able to develop our science.

Speaker 3 10:08

Can you walk us through the steps of undertaking a forensic autopsy?

Chris 10:15

Yeah, well, it's funny because we're often asked this when we give evidence in court. When we give evidence in court, or even if we aren't, we explain that we have a five-step process and the first step is to obtain a history, like you would if you go to the doctor. You know, I've got chest pain. Well, ours are obviously maybe from the patient, in the sense that they may complain to their relatives or people around them. I've got chest pain, I've got a headache and then collapse and die. We obtain the scene information. We do so. How were they found, you know? Was there bloodstaining at the scene? Are they involved in a road traffic crash? If a traffic crash, what does the car look like? I mean, is it badly damaged or is there no damage to the car which might point to it being not a traumatic death but a natural death with someone collapsing from a heart attack at the wheel?

Chris 11:17

We conduct an external examination, just the same as you would if you went to the doctor your own family doctor. The only difference is we examine everything and a family doctor typically will direct his examination to what you're complaining of. And then the different stage that we do is we do an internal dissection, looking at the organs, which is not available in the same way to other people. Now you may say well, what about doing CT scans or something like that? Well, we can do that these days, but they still are not as accurate as conducting the full dissection. And then, of those stages, the fifth stage. So we've had history scene, external internal examination. We then do ancillary testing, which is most commonly looking at tissue down the microscope and doing toxicology. So toxicology and I'm aware you're a toxicologist is one of our most vital ancillary tests and we work very closely with, uh, with toxicologists.

Chris 12:24

Because at the end of the day, you're going to die of one of three things in general terms you're going to die of natural diseases, you're going to die of trauma or you're going to die of drugs and poisons.

Chris 12:41

Now there can be an interaction and you may have two of those three or you may have all three. A good example of all three is in some police-involved deaths, where you have somebody who is intoxicated with drugs, say on cocaine, they have a bad heart and they get into a struggle with the police and then they die. So they have all three of our triangle. And when we've got all of that information we then put it together to render our opinion. So, if you like, the first five steps are gathering evidence and then we do our analytical stage to come up with an opinion on cause of death and, if I'm a medical examiner, on what in North America we refer to as the manner of death. In other words, is it a suicide, a homicide, an accident, natural diseases, or we can't determine what it is. So that's the processes we go through.

Geraldine 13:38

How do you handle situations where your findings are challenged?

Chris 13:43

Well, there's two points to this, I think. One is that we should be doing evidence-based medicine. So evidence-based medicine should come from our experience, but also knowledge from the literature that this pattern causes that result, and so if you're on solid scientific grounds, you should be able to point that out if you come under cross-examination to say you've got it wrong, which we do. The other point, though, is that we are an opinion-based science, have an opinion element to it in that if, say, you go to the hospital, and whether it's having a blood alcohol measured or a blood glucose measured, there is actually a range of results. We give one result, but it it actually could be plus or minus.

Chris 14:52

That's just the nature of the way laboratory medicine works, and in forensic pathology, you may be asked well, the injury you said was caused by a blow with a piece of wood, could it be caused by a fall against an object? And you either have to concede that based upon your knowledge, or you say no. I don't believe so, for the following reasons. And in court cases, your duty is to answer the questions, be calm, don't argue with counsel, just answer their questions, and if you're right, that will normally come through.

Speaker 3 15:47

Chris, have you worked on any high profile or notable cases and how have they impacted you?

Chris 15:53

multiple cases and how have they impacted you? What I would say is a high profile case rarely starts as a high profile case. It sometimes does. You know, if you have the shooting of a police officer on duty, that's going to be big news and I've dealt with those cases. I've also done reviews of TV stars who've died or been connected to a death. By and large they're straightforward, and you don't. They're not always the most tricky cases we deal with. They're not always the most tricky cases we deal with. There are some that can be contested and there may be potentially different causes of death. But in the others I mean the last police shooting death I did they brought someone back for trial after many years of not being able to arrest him because he had fled the jurisdiction and I presented my evidence and had no questions in cross-examination.

Chris 17:01

So you know, a high-profile case, yes, but not one that was difficult from a forensic pathology point of view. But there are cases that I've had colleagues who've had threats for the evidence, almost not before the evidence given, because people form perceptions without realizing what's going on. That's very rare. The one case where I did receive some threats I didn't take seriously but they were made by email. I received unsolicited emails saying that I was a despicable human being and so on, because they didn't like what I was, but I hadn't even said anything at that stage. This was the bizarre thing. So, yeah, it happens in high-profile cases, but I mean, to me it's been exceptional and I didn't feel threatened. But I have had colleagues who genuinely have been and I guess it partly comes with the territory, but none of us. We're all trying to do our best and give straightforward and honest evidence, and just that in this contentious world world, some people don't understand our role.

Speaker 3 18:19

Chris, how do you think forensic medicine, specifically forensic pathology, might evolve in the next decade?

Chris 18:30

It's interesting. People ask me about AI. Do I see AI, artificial intelligence, coming into forensic pathology? And the answer is not much pathology. We're developing techniques and patterns of injury, patterns of disease, and that's what we had to learn the 21st century. We started to develop techniques such as CT scanning for post-mortem and genetic testing for diseases, which are by no means they're useful. But the central tool in the next 10 years will be the autopsy, and it will be the autopsy as we conducted it 100 years ago, and there are interesting differences in the way the autopsy is used, in that some jurisdictions you know more commonly in continental Europe than in the English-speaking world tend to focus on crime, so they don't do as many autopsies in medical legal death investigation.

Chris 19:53

I still believe the autopsy has a vital role to play in non-criminal cases and for public health, and I think that will also is a focus that people are beginning to look at a bit more. We can use the autopsy. The autopsy still has a role in research, in clinical medicine, as well as in looking at trauma and drug-related deaths. So we still, for example, are trying to work out exactly when someone has died of a drug toxin versus another drug toxin. And why do I say that? Well, because many of our deaths in the fentanyl crisis that's occurred in North America also have cocaine on board. Well, did the cocaine actually contribute to the death or not? We don't actually really know. But is there any way we can try and tease that apart and say well, what does it matter? Well, it does. If you want to prosecute someone for supplying fentanyl causing the death, which you can do in North America, you can't do in England because of case law. So there's still a lot we have to learn and I believe that the autopsy will continue in the next 10 years to be the standard tool, possibly directed slightly in the next 10 years, to be the standard tool, possibly directed slightly, with a focus more on research and public health than sometimes we have done.

Chris 21:27

There are two types of autopsy. There are autopsies of documentation and there are autopsies of discovery, and the most interesting ones to do are the autopsies of discovery. And what do I mean by that? Well, the police come to me and say we've had a shooting, we've had a stabbing, they know what's happened, I just have to be there to document it. Maybe they don't know exactly the number of gunshot wounds, Maybe they don't know exactly the number of stab wounds. Were there defence wounds? Did they have any underlying disease that may have affected them? And then we'll do the toxicology that may have affected them and then we'll do the toxicology which may have affected behaviour. But more interesting are our sudden deaths. Often as you get older you realise where I don't actually know what the cause of death is until I've completed all my tests, and those are more interesting, I think.

Speaker 3 22:15

Chris, are there any unusual or surprising aspects of forensic pathology that people would not expect?

Chris 22:24

I think that people get a false impression of forensic pathology based on TV shows, but upon Silent Witness and upon similar shows that we Can Walk it or Midsummer Murders, you know, they give the time of death instantly. That's all baloney, it's not. We just can't do that, and they give far too much detail. Um, at the scene, it takes time to work these things out. So that's something I think that we often have to correct, and anyone who's in forensic science knows this. It's known as the csi effect. You have to tell the juries that a lot of what is in tv drama is exactly that it's drama, it's not reality, and so sometimes our tools are more powerful than people think, but more often than not they're not, as it's not as straightforward as is portrayed. So that's one thing, and it may well be that the public don't fully appreciate that the autopsy can be a significant tool for closure, to provide the family with knowledge of what happened to their loved ones. That could not be done without the autopsy.

Geraldine 23:42

Chris, how do you determine the time of death and what factors influence this estimate?

Chris 23:49

Well, the easiest way is to find out when they were last seen alive, when they were found dead, and say they died sometime in between the two. And that old joke is true. What you can do is sometimes you can narrow it down by well, if someone was found dead and it's a criminally suspicious death and the person who found them says, well, I came across them and they collapsed in my presence, I immediately called 999-911. And the ambulance arrives within 15 minutes. And they are. They have complete rigor mortis. You couldn't be going. That can't be correct.

Chris 24:27

There are people have looked at temperature, um cooling of the body. People have looked at biochemistry to see the changes in potassium in eye fluid. All of these are interesting but really don't get used much in casework because there are so many variables. Later we have things like forensic entomology, which can also be helpful. So that's insects get laid on bodies and maggots come, and then other beetles come and eat maggots and so on. It's known as the faunal succession, and we have specialists in entomology who do forensic entomology and that can be helpful to give a timescale of how long the body is there.

Chris 25:18

But in truth most cases don't need time of death and if they do. The limits to how accurate we can be often fall outside or within, depending on which way you look at it. What is known, so I mean it. You, if you do temperatures, typically they talk about you know the best is a five-hour window, and the police may say well, we already know that there's a four-hour window. So we can't do any better than that, than just ordinary observations. So textbooks have chapters on time of death. There's a whole textbook dedicated to time of death, of death. There's a whole textbook dedicated to time of death, and a lot of forensic pathologists will say it just isn't simple to use the various techniques.

Geraldine 26:08

Chris, what are the differences you note in practicing in Canada versus United Kingdom and what advice would you have for somebody considering that career?

Chris 26:18

Well, my advice to someone who's thinking about becoming a forensic pathologist is do so. It's been the most fascinating career as far as the. There are, in many respects, no differences between what I did in England and what I do in Canada. The autopsy practices are the same. Time has evolved to allow us to do one or two more tests. We do a different proportion of deaths in Canada to England. When I was in England I mean they have reduced, apparently, but we were doing nearly a quarter of all deaths as a medical, legal autopsy. It's about 8.5% in canada, but all the patterns are similar. I mean you, you may, you know I I get more um suicidal shootings in canada than I saw in england because we have more hunting guns, but not it's not. We don't see the firearms deaths that the united states does. We obviously have a have different patterns of drug use. It was all heroin when I was there and ecstasy. I wrote a bit on ecstasy in the 90s and we saw ecstasy and heroin.

Chris 27:31

Don't see much ecstasy, occasional case. Don't see a huge amount of heroin. We just see fentanyll but another drug called the nitazines or nitazines depending on which way you pronounce it. I've not seen a case in ottawa. They occur in england now. So some of those um differences, and then you may have one difference that we do deal with. You have to be cognizant of religious, cultural differences. So we have important indigenous populations in Canada that we didn and we have the same here. So some religions are not so keen on the autopsy as others. But here we also have important interactions with indigenous First Nations people, the Inuit and the Métis, who have been disadvantaged over the generations by colonialism and there is an antipathy towards authority, or there can be, so we have to be cognizant of that and respectful of their traditions as much as we're respectful of people who are of different faiths.

Geraldine 29:00

Chris is there.

Chris 29:02

Anything else you'd like to share with our listeners? Well, what I would say is that forensic pathology has remained. It's a different career for a doctor. There's no question. I don't treat people, although I arguably treat the community, and we have a public health role. We, I believe, are an integral part of society, assisting the criminal justice system but also public health.

Chris 29:28

I've been doing this now full time for nearly 35. I mean, since I started. I did my first autopsy over 40 years ago, so I've been doing it a long time. I've had the fortune to travel around the world. I've been doing it a long time. I've had the fortune to travel around the world. I've given evidence in Ireland, for example. I've been over in Northern Ireland. I've been in the Netherlands, south Africa, australia. It's taken me to do cases all around the world.

Collaboration in Forensic Science

Chris 29:55

But what's interesting is, in all of those places, the central thing about murder trials still is the post-mortem examination, which is why we can do it. And I think that if you are, what I would say is, if you are interested in doing it, then you need to explore it, but you do need to go to medical school, you do need to train in pathology. But if you do, and there are people who come and talk to me about this. You'll have a fascinating career and you'll meet wonderful people like you. Because one of the things I do want to say in all of this and we met um, we have mutual friends. Forensic pathology doesn't exist in a vacuum on its own. We are. We have team members, forensic biologists, forensic members, forensic biologists, forensic toxicologists. We have police investigators, we deal with lawyers, we deal with families, we deal with doctors because of patients.

Geraldine 30:56

So we're one cog in a big mechanism and it affords fantastic opportunities to meet other professionals who have a fascinating perspective on forensic science and medicine. Can I just say thank you, you are an absolute pleasure to be here. Thank you, and to our listeners, thank you for tuning in to another episode of the Analytical Zen Podcast. Be sure to join us next time. Stay curious.