Black eye for the medical profession (IV)
posted in - Nation, - Palmdoc |For those of you who want to read in detail the two autopsy reports, dranony in the Dobbs forums kindly pointed out the links from Malaysiakini:
The 1st post-mortem report (Serdang hospital)
The 2nd post-mortem report (UMMC)
As a quick reference, you can click here for the summary of the differences in the autopsy reports as reported by Malaysiakini.
Let me take you through what I think are the relevant and important bits from the two autopsy reports.
Note this item from the second autopsy
The glaring difference is that the abdominal organs were not removed for dissection in the first autopsy. Despite this, the first autopsy report declared them to be in “good condition” – see page 3/4 of the 1st report which mentions:
“Perut kosong. Hati normal. Limpa normal. Organ-organ lain diperiksa satu persatu dan dalam keadaan baik”
This would suggest the first pathologist concluded the abdominal organs were “ok” just by looking at them grossly and without further dissection.
The second autopsy included dissection of the abdominal organs and there is an accompanying report in page 8 which shows the histological (tissue) changes in the dissected organs. Here’s the important bit:
This means that there was evidence of kidney failure due to Acute tubular necrosis and the finding of myoglobin in the casts suggests that there was Myoglobinuria which results from extensive muscle damage (rhabdomyolysis) as the cause of the tubular necrosis and renal failure.
Both autopsy reports noted there was pulmonary oedema (liquid in the lungs) and pulmonary haemorrhage. Both autopsies noted extensive bruising and soft tissue injury though there were some differences e.g. the 1st autopsy claimed the spleen was normal whereas the second autopsy found haemorrhage in the spleen (not surprising since the abdominal organs were not dissected properly in the first autopsy). The 1st autopsy however concluded the cause of death was “Pulmonary oedema” without stating any possible causes of this. Pulmonary oedema by itself is an incomplete diagnosis. A young man does not suddenly develop pulmonary oedema out of the blue. A clinician is certainly obliged to determine the cause of the pulmonary oedema which includes acute renal failure. I am surprised that a pathologist would just leave the diagnosis as “Pulmonary oedema” without trying to elucidate what could have caused it.
The 2nd autopsy also concurred there was pulmonary oedema but concluded that the cause of death was Acute renal failure due to rhabdomyolysis caused by blunt trauma to muscles. The second report substantiated this with the findings in the kidneys which were dissected, something which was not done in the first autopsy.
Indeed as I pointed out earlier, this sort of Acute renal failure has been reported after physical torture, so to me the diagnosis does seem logical and the evidence provided fits with the scenario at hand.
We await the outcome of the MOH investigation. The DG has already declared the 1st pathologist has performed in an “ethical” manner. As for “competency”, I leave it up to you to conclude after reading the reports.
Related MMR posts:
Another custodial death. No foul play?
2nd post-mortem: Kugan was beaten to death
Black eye for the medical profession
Black eye for the medical profession (II)
Black eye for the medical profession (III)
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March 14th, 2009 at 11:49 am
Both reports were actually almost the same as DG commented. In fact the Serdang report already stated that Kugan suffered multiple blunt injuries. You can say that the 1st pathologist is ‘incompetent’ because he didn’t go after the cause of pulmonary edema (he probably statisfy that this is the cause without explaining the cause of pulmonary edema] but this doesn’t give anyone the right (especially the professional like MMA president] to accuse the doctor of accomplice with the police for murder. I don’t blame the layman as they may not understand the report and choose to believe the report sensationalised by the media. The professional should be objective and critical in their analysis and conclusion.
March 14th, 2009 at 12:00 pm
I don’t think the MMA president “accused” the said doctor of being an accomplice. In his words “If the second autopsy report is accurate, and there is much to say that it is, then the Pathologist who performed the first autopsy was either negligent in the performance of his duty or was coerced into reporting as he did. The MMA is deeply concerned with this in either case, and condemns the first autopsy and report.”
The question is how accurate the 1st report was, and did the pathologist perform as to be expected of a competent pathologist.
March 14th, 2009 at 12:11 pm
In fact the 1st report stated that ‘the blunt injuries adalah akibat DIPUKUL oleh alat tumpul’ This is not highlighted in Malaysiakini and this blog. Is there any agenda behind this or just want to echo tghe sentiment of current political scenario?
March 14th, 2009 at 12:14 pm
The issue is the final conclusion and whether or not the blunt injuries lead to death.
March 14th, 2009 at 12:47 pm
The issue is not the final conclusion. The issue is the media trying to sensationalise the story and trying to make this doctor as accomplice of murder. The issue is, in order to nail the police, they want this doctor to be criminally charged and put into jail. When reporting this story, media only selectively report the findings in the 1st report. No mention of how detail of the external injuries reported by the 1st pathologist. No mention of the media that the 1st pathologist in fact concluded that the external injuries are infact ‘DIPUKUL’. They chose to harp on the doctor on the conclusion because he concluded that Kugan died of pulmonary edema (which is technically not wrong] in stead of ‘DIPUKUL SAMPAI MATI OLEH POLIS’.
The doctor probably putting the cause of death as pulmonary edema because he failed to recognised the implication of police custodian death and proceed to find out what is the cause of pulmonary edema. He probably thaught that by concluding that the victim is in fact assaulted is good enough for him.
In an anology, pathologist may not sent all the toxicology or HPE request once the obvious cause of a MVA death found. Does pathologist send all toxicology tests or disect all abdominal organs for HPE on all the MVA death if crashed head injury is the obvious cause of death? Is examination of abdominal organs by inspection ‘not adequate’ by forensic standard? This question can only be answered by the independent experts in the forensic field NOT by layman or worse the lawyers. Not even DG or MMA president.
March 14th, 2009 at 1:00 pm
I don’t know how you can say the issue is not the conclusion. The first report did not link the beatings to the cause of death. The second one did and if not for the family insisting on the second autopsy, the information might not have surfaced.
It is in public interest to know if Kugan died in custody as a result of Police beatings. This should not happen in civilised society . I am sure you are not condoning custodial killing. This is not to say all Policemen are bad, on the contrary I am sure the majority of the Police force perform their work professionally. But the bad hats and bad practices should stop.
March 14th, 2009 at 1:14 pm
Yes but these are 2 different issue, dead in custody by police beating and autopsy reporting style. In fact I too can comment that the cause of death in the 2nd report was ‘incompolete’. The cause of death should be pulmonary edema due to acute renal failure due to rhabdomyolysis due to blunt trauma of skeletal muscle. Why the 2nd pathologist chose to omit the pulmonary edema in his report. Was this not related to the acute renal failure? The 1st report reported that there was blunt trauma (in fact he went on to conclude that this was due to DIPUKUL which is not even concluded in the 2nd report] and the cause of death is pulmonary edema. Both reports actually pointed to the same findings.
Nobody denied that Kugan probably died in custody due to police beating (the 1st report did not deny this at all] and justice need to be done but please don’t drag the doctor into this fiasco. I find it annoying to see professional like doctors will sing along with the lawyers spin story without giving thier critical analysis and neutral opinion based on facts. MMA should strive to find out the truth (the minimum thing the MMA president should do is to analyse both original reports before giving his opinion] not sing along with the popular sentiment.
March 14th, 2009 at 1:31 pm
How did you know the MMA president did not view the original reports given the fact they are even available online? Isn’t it presumptuous of you to accuse the MMA President of merely “singing along with the popular sentiment”?
I am glad you agree with the conclusion. The second pathologist did not omit the pulmonary edema – this is clearly stated in his findings. What he did was conclude what the underlying cause of death was. For the uninformed, saying “Pulmonary edema” as the cause of death is as bad as saying “Heart failure” is the cause of death.
March 14th, 2009 at 1:37 pm
If he indeed read those report, his media statement just show that he do not understand the medical description and terms in the reports and let alone critically analyse it. So I chose to presume that he hasn’t read the reports yet.
March 14th, 2009 at 1:40 pm
What part of his statement shows he did not understand the medical description?
March 14th, 2009 at 8:50 pm
Back to the point that Malaysiakini raised about starving that inmate, I am not sure how Malaysiakini came to this conclusion. Any suggestions?
http://chenghiang.wordpress.com/2009/03/05/death-in-custody/
March 14th, 2009 at 11:05 pm
I don’t think the 2nd post-mortem report suggests any significant “starvation” so you could put that to dramatization. But what do you think of the NST declaring right off that there was “no foul play”? Which is worse? Covering up facts or dramatization?
What I think is certain is that Kugan was beaten to death. His death was not due to “natural causes”. Who did it? Well, he was in Police custody at the time of death so you can only guess who did it. No post-mortem can ascertain the actual guilty party so it’s up to the AG and the authorities now. If we were to rely only on the first post-mortem, we would have an inconclusive “Pulmonary oedema” of uncertain cause. Although there were recorded soft tissue injuries probably due to beatings, the 1st pathologist did not tie it up with the Pulmonary oedema. The culprits might have got away. The second post-mortem suggests very strongly that Kugan died as a result of ARF due to Rhabdomyolysis from muscle injury (the Pulmonary oedema one can surmise is a secondary phenomena from the ARF). Therein lies the importance of the 2nd post-mortem which shows a link between the beatings, muscle injury and the actual underlying cause of death. ARF from rhabdomyolysis can occur very fast. I have personally seen a case of ARF from myoglobinuria occurring from very strenuous exercise within about a day.
March 15th, 2009 at 4:53 am
Thank you Palmdoc! Took you a while to acknowledge that Malaysiakini is not a reliable source of news.
“Post-mortem revealed no foul play in the death of police detainee A. Kugan at the Subang Taipan police station.” NST from the link posted by Palmdoc.
Did the 1st post-mortem at any stage suggested foul play?
March 15th, 2009 at 7:30 am
No source of any Malaysian news is 100% reliable, least of all the main stream media when it comes to politics btw since they are beholden to their polical master. Malaysiakini is not infallible either but I would not label it as “unreliable” going by their past record and they are not owned by any political party.
The 1st post-mortem showed injuries which were consistent with beatings. The cause of death was stated as “Pulmonary oedema” which was not qualified further. This in itself would give rise to suspicion something is not right, but there is insufficient evidence. However to declare outright that there was “no foul play” makes one think someone wants to hastily cover things up. Would you accept the first post-mortem at face value and accept (the NST declaration) there was “no foul play” and then leave it as that? “Pulmonary oedema” of unknown cause?
March 15th, 2009 at 11:34 am
Please don’t spin the story. The doctor never said or documented no foul play in anyway. The no foul play was said by the police and assumed by Malaysiakini that this was the doctor’s conclusion.
March 15th, 2009 at 11:58 am
Please don’t read spin when there’s no spin. Nowhere did I say the doctor said or documented “no foul play”. That was the report in the NST. The first doctor merely performed a post-mortem which said the cause of death was “Pulmonary oedema”. The conclusion was inconclusive as there was nothing concrete to link the injuries to the Pulmonary oedema.
Anyway I think this is just going round and round in circles. We should just leave it to people to formulate their own conclusions and for the MOH/AG to complete their investigations.