The autopsy report
Forensic investigations in India are done by doctors who are neither trained nor qualified, leading to endless legal stalemates
At 23 minutes past noon, the second body of the day arrives, laid out flat on an open trailer harnessed to a tractor. The body is covered in a white sheet. The dead man’s name is Ram Chander: 25 years old, a labourer. He was found this morning slumped under a tree inside a primary school in his village, with a noose around his neck. Next to his body squats his father, Ram Pal, a small man with short salt-and-pepper hair tamped down on his head. Ram Pal’s eyes are closed.
As the tractor comes to a stop under a towering Seemal tree inside the district mortuary compound in the town of Barabanki, Uttar Pradesh—an hour’s drive from the state’s capital, Lucknow—Ram Pal steps off the trailer and looks around with dazed eyes. He notices a battered police car and walks up to it. From the back of the car protrudes what is unmistakably the feet of another body, wrapped tightly in a white sheet. This was the first body to arrive, at 9:37, and it belongs to a government clerk, the victim of a hit-and-run.
The clerk’s brother has fallen asleep under the tree. The police have not managed to get the inquest papers required for an autopsy to begin, and after three hours of restless and silent pacing, during which the clerk’s brother searched for, and failed, to find anyone to speak to about the situation, he gave up and lay down to rest. Now Ram Pal joins the wait.
At one in the afternoon, two policemen arrive with another body—a 72-year old man who died in prison while serving a life term for murder—in a ramshackle ambulance splattered with dried blood. The policemen bang loudly on the black gate that separates the parking lot from the autopsy rooms. The mortuary manager opens it a sliver to speak to the police. The families of the dead, roused by this new development, gather around. The inquest papers have come. The bodies are piling up.
The gate opens wider and Rakesh Kumar steps out. He is 45 years old, dressed in oversized red boxer shorts, a frayed t-shirt that sweeps over his belly, a thin pair of glasses with a broken bridge fixed with tape, and a pair of worn-out rubber slippers. His hair is cut close to the scalp and he has a drooping moustache.
The police know him well: he does all the autopsies. They offer him a pint bottle of whiskey and cajole him to start. He goes into the guardroom at the corner of the compound that doubles as his home, pours himself a stiff drink, drains it in one gulp, stuffs tobacco in his mouth, and pulls a pair of white rubber gloves onto his hands.
At 13:37, Rakesh has the body of the clerk laid out on the stone table in the cramped autopsy room, lit by a bright, naked bulb hanging from the ceiling. He takes a crude, rusted, knife and makes the first incision: a carefully drawn straight line—with a slight leftward deviation to bypass the navel—beginning from just under the adam’s apple, and ending just above the penis. The line splits the upper layer of the skin. Now he picks a six-inch knife, as rusted and rough as the first one, its handle held in place with a twine of blue plastic. He begins to cut through the layer of fat under the skin along the incision, and then through the flesh.
“You have to be careful, you don’t want to cut through any organs, or the post mortem will be ruined,” Rakesh says.
Rakesh is not a forensic surgeon. He is not a doctor. His official designation is ‘safai karamchari’—he is the mortuary’s cleaner. He is barely literate. Today, he will cut open six bodies, inspect them inside and out for injuries, remove the organs and weigh them before putting them back into the stomach cavity, stitch the bodies up, wrap them in plastic and a cotton sheet, and hand them back to the families.
The doctor actually assigned to do the autopsies will come in half an hour after the commencement of the first body, and will get to wear a mask, gloves, and a gown; but he will never once touch a corpse. Instead, he will observe and write his reports, often asking Rakesh to narrate what he is seeing. The doctor will leave before the last body—the prisoner—is barely open, having already written and signed the autopsy report for the old man.
Autopsy: Greek, ‘to see for one’s self’.
In the event of an unnatural death, the autopsy or post-mortem examination of a body is an invaluable and essential tool in investigating the probable cause and manner of dying. For the police, the autopsy report forms the backbone of an investigation. For the judiciary, it is critical evidence that can, with a single conclusive expert statement—‘the probable cause of death is suicidal and homicide can be ruled out’—determine the outcome of a case.
In India, an autopsy is done for every ‘unnatural death’. This may mean murder, suicide, death from an accidental fall or drowning, death from a traffic accident, unexplained sudden deaths, any unidentified body found in any condition (including foetuses), and any hospital death where the family of deceased believes that the patient died due to negligence. The process kicks in automatically when a person dies.
Though there are no figures available for the number of autopsies done in India, the National Crime Research Bureau (NCRB) does provide a figure for the total number of deaths where criminal cases were registered in 2016, excluding traffic accident casualties: 1,95,006. NCRB’s latest data on suicides is from 2015, where it recorded a total of 1,33,623 deaths. The same year, they reported 4,13, 457 accidental deaths, including traffic accidents. Assuming similar numbers for 2016, and that due process was followed for each death, that’s at least a total of 7,42,086 autopsies done in 2016—the number is bound to be higher, since it does not include unidentified bodies, for which no statistics exist.
A two-month investigation by Mint has revealed that the vast majority of this staggering number of autopsies that are performed every year are of little value, and in fact, often have the exact opposite effect of what it is supposed to: riddled with errors, or done incompetently, they lead to justice being denied. Mint spoke to doctors, forensic scientists, police officers, lawyers and judges across the country; analyzed autopsy reports, inquest reports, court judgements, post-mortem reviews, papers in medical journals, and statistics from various official sources and RTIs; and witnessed autopsies being performed at multiple mortuaries.
“An autopsy is an instrument of medico-legal investigation of death,” says Dr Sudhir Gupta, who heads the Forensic department at AIIMS, New Delhi, India’s finest forensic facility. “This is not just about cutting up a body and filing a report as a formality. But because of the sheer volume, that’s what is happening in most places.”
Dr Gupta’s colleague Adarsh Kumar, a professor of forensic medicine at AIIMS, says that roughly 80% of these autopsies are being done by doctors who have never been trained in the field.
“It is for them simply an enforced duty that needs their signature,” he says. “Because of this the problems that are created—in terms of delivery of justice, in terms of finding out what really happened to the deceased—are huge. And there are thousands of cases like that, uncountable.”
Add to that the lack of a uniform set of guidelines for conducting autopsies. Since health and police fall under the control of state governments, each state has its own protocol; some states have a single page of instructions, some have detailed manuals, and some are following guidelines issued as far back as 1964. This presents a peculiar problem, since the autopsy report is linked to the Criminal Procedure Code of India, or CrPC, which is uniform across the country.
Dr Indrajit Khandekar, professor of forensic medicine at the Mahatma Gandhi Institute of Medical Sciences in Sewagram, Maharashtra, points out that there is a fundamental problem with the law (174 CrPC) that governs ‘unnatural death’ as well. Framed in the 1860s—three years after germ theory came into existence, when there was little concept of specialist doctors, and antiseptics were yet to be invented—the law simply says that the examination of the body be done by a ‘qualified medical man’.
“So what have the states done? They have authorized all doctors in government service—general practitioners, pediatricians, whoever—to do autopsies,” Khandekar says. “So, a person who has never done a single autopsy in training, and in many cases, have never even witnessed one in school, is expected to do it.”
The problems follow thick and fast: mortuaries without basic facilities where bodies are left to decompose, piled on top of each other, without refrigeration (many mortuaries have no access to running water or electricity). Dr Sachin Meena, assistant professor of forensic medicine at Government Medical College, Kota, in Rajasthan, describes his own mortuary as ‘hell’. In most of them, there are no protective gowns or masks (neither are bodies screened for infectious diseases), and sometimes, no gloves. Dr Dharmaraya Ingale, a forensic doctor and the principal of Karuna Medical College in Pallakad, Kerala, says that the ten years he spent as a medical officer in the district of Bijapur in Karnataka were like a ‘nightmare’, where he was forced to do autopsies in the open, next to a water body, since the mortuaries had poor lighting lacked running water. “When there were no gloves, we found discarded plastic packets to wear on our hands,” he says. “Nothing has changed.”
On the morning of 28 May in 2014, residents of Shahdatganj, a village in Uttar Pradesh, found two girls from the village hanging side by side from the thick branch of a mango tree. The girls, one 14 and the other 15, were cousins. They had gone missing the night before.
When the bodies were found, the villagers gathered around the mango tree and prevented the police from bringing the bodies down, alleging that the police would try to manipulate the case to show that the girls had killed themselves. The real story, the villagers and the parents of the girls agreed, was that they had been abducted, raped, and murdered.
The girls remained hanging, as crowds, reporters and cameras poured in. The day turned to night by the time officials could reassure the crowd that there will be an unbiased investigation, and the bodies were brought down. Three medical officers were called in to do an immediate autopsy at the primary healthcare centre at the village. One of the doctors, Pushpa Lata Pant, was assigned the younger girl. She gave the cause of death as “asphyxia due to ante mortem hanging”, which means that the girl was alive at the time of the hanging. Dr Pant also noted that the girl had ‘blood clots in around the vaginal area, clots and abrasions around the hymen’.
Based on the confirmation of rape from the autopsy report, the police arrested five suspects. A few days later, the police declared that the suspects had confessed to their crime. The news rippled around the world.
Then the case took a strange turn when a special investigation team took over from the local police and sent the autopsy reports and photographs to forensic specialists at AIIMS, New Delhi. Dr Adarsh Kumar was assigned the review.
“When I read the report and saw the photographs,” Dr Kumar says, “I could tell that whoever did it, knew very little about forensic examinations.”
As he examined the photograph of the girl’s genitalia from the autopsy scene, he could see no signs of injuries. Where did the blood in the vagina come from then? Dr Kumar turned to the girl’s under garment. Under magnification, he found traces of a sanitary pad. He told the investigating team that he wanted to speak to the doctor who did the autopsy.
“Dr Pant told me it was the first time she was doing an autopsy, and that she had no training in how to do one,” says Dr Kumar. “She said she did not touch the body, that a sweeper did everything, that there was very little light in the autopsy room, and that she was scared of the crowd outside.”
Dr Kumar says that Dr Pant told him that as soon as she saw signs of blood on the vagina, she made up her mind that the crowd outside were right, that the girl had been raped. She did not wait to look further.
Dr Pant, who did not respond to requests for an interview for this article, came out publicly and told the press soon after her conversation with Dr Kumar that she had never done an autopsy before and was not qualified to do one. “When you get an order, you have to comply with it,” she told reporters.
On 12 June, the CBI took over the case, and their lab results found no traces of semen or male DNA on the samples sent to them. The case was closed five months later as suicide.
“Can a doctor not specifically trained in forensic examinations diagnose a case like this? It’s almost impossible,” says Dr Khandekar. “But the doctor can’t refuse, it would be illegal. So, what do they do? They go ahead with whatever the police tell them and they are done with it.”
The most unsparing example of everything that can go wrong with a post-mortem investigation—a case that came up again and again through the course of the interviews for this article—are the murders of Aarushi Talwar and Hemraj Banjade on 16 May, 2008.
Aarushi’s autopsy was done Dr Sunil Kumar Dohre, a GP, and the deputy chief medical officer of Noida. Hemraj’s autopsy was done by Dr Naresh Raj, a pediatrician. Both doctors—in their haste to side with the police theory that the murders were committed by Aarushi’s parents after they found their 14-year-old daughter having sex with their domestic help, Hemraj—made flagrant errors in their reports. The reports were taken apart in court and formed the basis of the Talwars’ acquittals in 2017.
“When we find post mortem reports like this, when we see that the doctor was not qualified to do it, then that becomes our target for cross-examination,” says Vishal Gosain, one of Delhi’s top criminal lawyers, who aided his colleague Rebecca John in the Talwar’s defence. “We attack the credibility of such reports.”
In Aarushi’s PM report, Dr Dohre had written that he found ‘no abnormalities’ in her genital area, but later, in his court deposition, he said that the murdered girl’s vaginal orifice was so open that he could clearly see the vaginal canal.
Forensic specialists and medical text-books proved to the court beyond doubt that Dr Dohre’s testimony was fundamentally flawed: it is impossible for the vaginal orifice to be found open and for the vaginal cavity visible, unless the genitalia were manipulated after rigor mortis—the stiffening of the muscles of the body post death—was already well-established, which happens at least four hours after death.
On being cross-examined, Dr Dohre made a startling claim—that he had never inspected female genitalia before, only seen it being done in medical school, ‘about 20 years ago’, and that Aarushi’s vaginal swab was taken by the ‘hospital sweeper’.
Justice Kannan Krishnamoorthy, who was a judge with the High Court of Punjab and Haryana from 2008 to 2016, and now heads the Railway Claims Tribunal Board, is the editor of Modi: A Textbook of Medical Jurisprudence and Toxicology, the most commonly used textbook for forensic studies in medical colleges, and the book to which courts turn to, as it did with the Aarushi/Hemraj case, for forensic references.
In the Aarushi case, he says, the doctor “was grossly under-equipped”. But it did not surprise Justice Kannan. “Not only is there no doubt that most doctors doing post mortem work have no training in it, but because the system forces them to do it, and at a volume that no one can handle, they do a terrible job of it.”
To illustrate, he pulls out a folder from a stack on his table and lays out the crime scene photos of a man found dead on a platform in New Delhi. The man’s family claims he fell off the train and died of a head injury. The photographs show a man in his late 30s, with a moustache, wearing a white shirt with pale stripes, blue jeans, and with one foot in a slipper and the other one bare. There is no sign in the photographs of blood or external injuries and the clothes are in good condition.
Justice Kannan then shows me the autopsy report, and points to the section titled ‘General Description’, where the doctor has described the victim as wearing “T-shirt, pyjama, pair of shoes, under garments, clothes smeared with blood, torn, with grease stains’. The cause of death is given as “combined effect of cranio-cerebral damage consequent upon blunt force impact’—in line with the police claim that the man fell off the train and died of a head injury.
“I did not want to assume anything…maybe the doctor does not know the difference between jeans and pyjamas?” Justice Kannan says. “So I called him in and showed him the photograph without telling him about the case and asked him to describe the clothes to me. He said, ‘white shirt, blue jeans, chappals.’ Then I showed him his report. He was shocked. He said, ‘I must have mistakenly put in the details of another victim’.
Why is it that most autopsies are done by doctors not qualified to do it? The answer is absurdly simple: The MBBS graduates and non-forensic specialists entrusted with doing post-mortems in India are never made to do an autopsy during their training.
Dr Khandekar, who filed a PIL on forensic curriculum in 2014 after collecting data and teasing information out of the Medical Council of India (MCI, which sets the curriculum for medical education) via RTIs, says that in the MBBS course, forensic post-mortems is the only clinical discipline that does not have a prescribed practical teaching schedule, practical examinations, or a clinical posting for internship.
“The only thing mandatory in forensic studies is that you write a theoretical exam,” Khandekar says. It’s the equivalent of someone becoming a surgeon simply by reading a book, without ever having to hold a scalpel.
For doctors graduating from some government medical colleges, the only requirement is to simply observe 10 autopsies being done. Most doctors I spoke to said that they either did not get, or chose not to attend, even those ten during their schooling. In private medical colleges, which are not authorized to do autopsies in any state except for Karnataka and Puducherry, even this basic minimum is missing.
Some states, like Uttar Pradesh and West Bengal have even stranger rules: in both these states, the forensic departments in even government medical colleges are not authorized to do autopsies. Only government medical officers—a tiny fraction of whom are forensic specialists—are allowed to do it. (The rule is exactly the opposite in Delhi, which has some of the best practices and infrastructure in place for post-mortems, and where only forensic doctors handle the cases.)
“So here you have a situation which makes no sense at all,” says Dr Jagadeesh N Reddy, professor of forensic medicine at Vydehi Medical College, Karnataka. “You have forensic specialists training budding forensic specialists, but neither the teachers nor the students ever do a single autopsy, which, in turn, is being done by a doctor who has no training in it.”
Dr Reddy, who helped the MCI to revamp the curriculum for forensic studies in 2012, making clinical training and examination mandatory among other points, says that nothing has changed yet. “I have no idea when the new curriculum will be put in place,” he says.
“You know the phrase, ‘what the mind does not know the eyes cannot see?’” Dr Sudhir Gupta asks me in his office at AIIMS, New Delhi.
“That is what is happening with forensic investigations in India. The infrastructure is completely inadequate, there are no uniform guidelines, the training is not there, and there is no provision for trained assistants in a mortuary, and no assessments. Compare that to an Operating Theatre, which is ruled by strict guidelines, and is subject to assessments all the time. We have a moral, medical, and legal obligation to change this.”
When he was in school, Dr Indrajit Khandekar, who is at the forefront of a fledgling effort to change forensic practices in India, was sure that he would be a farmer. His father was a high school teacher, but the family had a 10-acre farm near Sewagram, a rural town in Maharashtra where Mahatma Gandhi built a complex of mud-and-bamboo cottages in 1936 to realize his ideal of living a simple rural life, and where the first meeting of the Quit India Movement was held in 1942.
All the way till high school, Khandekar had spent most of his time on the farm, becoming proficient in each aspect of agriculture. But when it was time to pursue a college degree, he found another calling.
“My uncle was the dean of a medical college,” Khandekar says. “Seeing him, my brother became a doctor. Seeing my brother, my older sister became a doctor. Seeing the two of them, I became a doctor.”
Since 2007, when he was appointed to a teaching post at MGIMS hospital, the soft-spoken, stocky, doctor has been challenging accepted practices with the obdurate zeal of a reformist.
In 2010, Khandekar filed his first PIL, to cover every aspect of what he termed ‘the horrendous quality of medical examination of sexual assault victims’, including a challenge to the brutal and unscientific ‘two-finger test’, where a rape victim was mandatorily subjected to the examining doctor inserting fingers into the vagina to ‘test’ it for laxity—if it allows one finger, the victim is ‘not habituated to sex’, and if it allows two, then the victim is ‘habituated’. The PIL played a central role in the Supreme Court banning the test in 2013.
In his latest PIL, filed in 2016, he questioned the interpretation of 174 CrPC, the law that governs autopsies, claiming that thousands of autopsies are being done in cases where they are clearly unnecessary, leading to an inhuman system. Khandekar was unsparing. In the report, he likened mortuaries to abattoirs. In July 2018, the Law Commission of India called him to discuss proposed changes to 174 CrPC.
The Sewagram model
Not content with prodding the government machinery with PILs and RTIs, Khandekar also began to put his beliefs into practice.
The first hurdle was to negotiate the deeply entrenched convention of police ordering autopsies without reasonable cause. He began collecting data from the hospitals in the district of Wardha in Maharashtra, under which Sewagram falls, to see how many times an autopsy has been done in a case where the death occurred post-hospitalization and where the attending doctor had given a cause of death already. He found that more than half the autopsies done in Wardha in 2015 were done after a cause of death had already been established. Khandekar approached the then superintendent of police of the district, a young officer called Ankit Goel, and together, they introduced two clauses to the inquest format—a) ‘Have you collected the death certificate from the attending doctor? Yes or No? If No, reason why;’ b) ‘Any doubt raised by relatives over the cause of death? Any doubt you find in the cause of death? Yes or No? If Yes, give reason.’
It was a clever move; Khandekar was simply making the police own their decision.
“It’s logical and legal, though it’s not simple,” says Goel, who is now the DCP of Thane in Maharashtra. “there is a fear that without doing a PM we are not fulfilling our duty and that we will be later held accountable by court, or by senior officers.”
The changes had an immediate effect: In 2017, a year after the new inquest format was made official by Goel, 377 autopsies were waived off in Wardha—27% of the number of unnatural deaths that were reported that year.
But the change that Khandekar believes will have the most far-reaching effect in medico-legal cases is the setting up of a forensic unit attached to the emergency department of MGIMS in 2012. What that does is remove the crucial gap that exists between the reporting of a potential medico-legal case to a hospital, and the actual forensic investigation of the case, which usually only begins when and if the patient dies.
Khandekar gives the example of a person who has been brought into Emergency after a suspected case of poisoning. The first line of treatment is always to wash out the stomach to get rid of the toxins. Depending on how many days the patient survives, multiple such washes may be administered. At this point, apart from an effort by the police to record the statement of the patient, no other investigative steps are taken. That begins only if the patient dies, in which case, according to the system followed everywhere in India, there will be a full autopsy, and the victim’s viscera will be sent for tests to a forensic lab.
“But now, because so much has been done to try and flush out all the toxins when the patient was alive, the viscera will test negative for poison,” Khandekar says.
Khandekar looked at the data from past cases of poisoning where the patient was admitted alive at MGIMS and died during treatment. In every single case, the labs reported that they could find no trace of poison.
“We had no cause of death to show,” Khandekar says. “No evidence. The cases end in acquittals.”
What is needed as effective evidence is a blood sample and a sample of the stomach wash on the day the patient is admitted. But there are neither guidelines nor laws regarding this, and most emergency departments in Indian hospitals do not have provisions for collecting evidence from a suspected medico-legal case.
By setting up a forensic unit at the emergency department in MGIMS, Khandekar ensured that when a patient suspected of poisoning is brought in and administered a stomach wash, his unit is ready to preserve a sample of the wash; that they are on hand to collect a blood sample immediately so it could be sent to a forensic lab.
“Every change that happened made things more efficient,” says Goel, the former superintendent of police in Wardha. “We got reports quicker, they were of far better quality…we could build cases.”
The thrill of the chase
When Dr Sudhir Gupta stood over the collection of bones that were suspected to be the mortal remains of a young woman called Sheena Bora, he thought of the bones of birds that fly long distances. He thought of the time he had read about the Sushruta Samhita, the ancient Indian text on medicine and surgery, where the bones of migratory birds were heat-tempered to make the fine, tough, two-sided blade of a lancet.
This set of bones he was looking at, they belonged to a body that had been set on fire. He could see the charring. The murderer or murderers had burnt the corpse to conceal the identity of the victim in case the body was found. They had made a mistake. The heat had tempered the bones and made them tough. Even though they had been dug up on a rainy afternoon from a hidden grave inside a forest off the highway that goes from Mumbai to Goa, where they had spent three years buried in a hot and humid place, the bones were perfectly preserved.
“The burning had heat-tempered and made the bones decomposition-proof,” says Dr Gupta, head of the department of forensics at AIIMS, New Delhi. “Otherwise, bones decompose significantly within a year and a half, and our work would have been much harder.”
Yet, in his three decades as a forensic specialist, this was one of the biggest challenges he had ever faced—to find some clues that can shed some light on a murder that took place three years earlier from nothing more than skeletal remains.
The facts of the case, in a nutshell, were this:
A driver called Shyamvar Rai was arrested in 2015 by Mumbai Police for the possession of illegal firearms. Rai cut a deal with the police: he would reveal to them his role in a murder in 2012 that the police did not even know about, in return for a lenient sentence. Rai told the police that on April 24, 2012, when he was working for Indrani Mukerjea and her husband Peter Mukerjea, well-known media moguls based out of Mumbai, he was roped in by Indrani to help her murder her estranged daughter from an earlier marriage, a 25-year-old woman called Sheena Bora. Rai told police that Indrani drugged Bora in the backseat of the car as he drove them around Mumbai, before strangling her to death. The next day, Indrani asked Rai to drive her to a predetermined spot along the Mumbai-Goa highway with Bora’s body, where they set the body on fire and then buried the remains.
A month later, a man living in a village near the spot where the body was buried accidentally stumbled on the skeletal remains. A spot post-mortem was done by a doctor with the help of the local police, some bone samples were collected and sent to Mumbai’s JJ Hospital, and the rest of the skeleton was reburied at the same spot. Nothing else happened in the case. The body could not be identified, and no cause of death could be determined. It was not until Rai’s confession in 2015 that police could connect the unknown body from 2012 to Sheena Bora. The skeletal remains were dug up again for a fresh forensic examination and sent to Dr Gupta and his team to establish the identity of the exhumed skeleton.
The team at AIIMS first identified if the bones were human or not. Then they carefully inspected each bone for any signs of injury—was this person stabbed? Shot? Assaulted with a blunt object? They tried to fix the time of death, which required state of the art chemical analysis techniques. Then they began to reconstruct the bones in their normal anatomical arrangement, and with the help of cutting-edge imaging, and DNA and tissue analysis, began to form an idea of the height, weight, sex, and probable physical features of the person when she was still alive. The results were a close match to Bora. They found a particular kind of filling in a tooth and asked the CBI to match it with Bora’s dental records. It was a match, as was the DNA with the DNA taken from Indrani.
“It took us a whole month,” says Dr Gupta. “And at the end of it, we gave the CBI three opinions in our report: That this body is probably of Sheena Bora; that she probably died these many days ago; and that the body showed no signs of external injuries, which meant she could have been killed by strangulation.”
This is an example of an ideal autopsy, performed by a team of experienced and well-trained forensic specialists with access to a great amount of resources. It is also an example of the power the idea of an autopsy holds for the police, the judiciary, as well as governments: that it can reveal everything about the death of a person.
“There are many limitations to what you can find from an autopsy,” Dr Gupta says. “And it is the need of the hour for all stakeholders, especially the judiciary and the police to try and understand the limitations of post mortem examinations and what they can expect from it.
“Most of our post-mortems are being conducted even in well proven cases only for the sake of completing conventional formalities, and this puts such a great stress on the system that it is always on the point of collapse.”
The needless cut
According to The National Association of Medical Examiners, which sets the guidelines for forensic examinations in the US, a doctor ‘should perform no more than 250 autopsies per year’, and that when that number crosses 350, ‘mistakes are likely to be significant and involve errors of judgement’, leading to ‘faulty attributions of blame, wrongful prosecution or exonerations, and missed homicides’.
In India, the numbers are staggering. The single mortuary in Barabanki in UP, staffed with one sanitation worker and a single doctor on duty on any given day, did 972 autopsies in 2017. The King George Medical College in Lucknow did 4894 autopsies last year. AIIMS, New Delhi had 2618 cases in the same year. Osmania General Hospital in Hyderabad performed 4757 autopsies last year. Government Medical College, Nagpur, did 3433, more than half of which, according to a forensic doctor at the hospital who did not wish to be named, ‘were done after there was no doubt about the cause or manner of death already’. Accounting for the number of doctors at each of these hospitals, the average number of autopsies done by a single doctor in a year works out to over 700.
Dr Jagadeesh Reddy, one of the foremost forensic experts in India, says that the high workload ‘completely compromises the quality of the PM…. the scientific, medical nature of the investigation is lost’.
“Is it possible for a single doctor to examine and dissect even 6 or 7 bodies in a single day?” Asks Dr Reddy. “Impossible. But that’s what is happening now. The system is engineered to fail.”
Instead, doctors suggest, a simple screening method will rule out the need to do an autopsy in a very large number of cases, a decisive example being victims of traffic accidents who are brought to hospitals alive but die subsequently—a group that accounts for nearly a third of the roughly 7 lakh autopsies done in India every year.
Khandekar shows me the death certificate of a man who was admitted to a major government hospital in Nagpur on the first of October, 2017, with a severe head injury after a bike accident. After multiple surgeries, the patient died of his injuries on 18 January, 2018.
“And yet, this certificate says, ‘cause of death to be decided after post-mortem,” Khandekar says. “If a patient is under your care for 3 months, and you have done multiple surgeries, tests, scans, and still you need an autopsy for cause of death, what is the use of you being a doctor? Or do we just like dissecting bodies? What can you find by opening the body which you did not find in your full CT scan?”
The burden of doing a clearly unmanageable number of autopsies makes the system profoundly ineffective, leading to vicious practices like making sanitation workers perform autopsies, most often without basic safety measures.
At 14:25, less than an hour after Rakesh had begun opening the body of the clerk in Barabanki, he walks out of the autopsy room and gestures to the clerk’s brother with a bloodied glove. He needs to identify the clerk’s body before it’s wrapped. The clerk’s brother comes out a minute later and throws up in a corner. He is crying. When he went into the room, there was the clerk, lying on the floor next to the autopsy table, wrapped except for the head, and on the table he saw something he was unprepared for: the fully open body of Ram Chander, the labourer who was found with a noose around his neck.
The clerk’s brother is consoled by Ram Chander’s father, Ram Pal: “At least it’s over,” he says.
Rakesh wants it to be over too. “We get so many bodies every day, we have to work fast, really fast,” he says. “That’s what I’m here for, to use the knife with speed. I have six bodies to do today already and more can come in.”
He shows me his tools: three rusted knives—two small ones and one large—which he says he specifically got made from a blacksmith who makes knives for slaughterhouses; a small iron wedge—‘like the ones you split wood with’; and an ordinary hammer to break open the skull.
He leaves Ram Chander’s open body for the doctor on duty, a surgeon who has worked as a medical officer for a decade, to inspect. He walks out and tells Ram Pal to buy two gunny sacks, a couple of kilos of salt, a tub of glue, and a white sheet. The salt, glue and gunny sacks are to send the clothes and viscera—parts of the lung, liver, heart, spleen, stomach, and intestine—to a forensic lab.
Ram Pal nods in understanding and says in a low voice, as if to no one in particular: “There were mustard flowers and leaves in his clothes when we found him.” Then he leaves to buy the stuff.
I ask Rakesh if he feels emotionally drained because of his work. He smirks. “This is just a job,” he says. “You get used to it. When I had first come here, it was very hard. I was traumatized. At night, I could not sleep here, I used to walk far from here and sleep on the pavement. Now I can sleep next to a body, no problem.”
Rakesh, who used to be a sanitation worker in a rural hospital before, was transferred to the Barabanki mortuary six years back. He was taught everything he knows about autopsies by the cleaner who worked here before, a man called Channu. His ‘training’ lasted six months. In that time, the only bodies Channu allowed Rakesh to handle are the unidentified ones.
Rakesh remembers the first body he took a knife to. It was decomposed almost beyond recognition.
“It’s the smell,” he says. “It went inside my head and would not leave. For weeks. No matter how many times I bathed. I could smell it all the time, and I thought everyone around me could too, but when I asked, they said there was no smell!”
Rakesh says he begins drinking before he touches the first body of the day and stops drinking when he goes to sleep. “I won’t be able to do any work without alcohol,” he says.
Doctors agree that sanitation workers handle all autopsies, often unsupervised, at the district and rural level, yet they point out that some metropolitan cities like Delhi are exceptions. While this is largely true, there is at least one place in Delhi where sanitation workers do all the work, the Sabzi Mandi Mortuary, the oldest such facility in the city.
The cleaner at the facility, which is attached to Aruna Asaf Ali Hospital, spoke to me on conditions of anonymity. He took me inside and opened the two refrigerated rooms that were installed in 2016. There were bodies lying everywhere, often two or three on a single stretcher, some stacked atop each other. Most of them were covered with white sheets. The register at the mortuary said there were 73 bodies in the rooms, all of them unidentified. One of them has been lying around for 97 days.
The sanitation worker took me to the autopsy room, which had four tables. On one table lay his tools, which were identical to the ones used by Rakesh.
“We have never got any surgical equipment,” he says. “We only started getting gloves from 2010. I started here in 1991, and I used to do everything with bare hands.”
The cleaner’s father worked here in the same capacity as well.
“I first started with carrying bodies,” he says. “When I got used to that, my father started teaching me to cut them. Doctors here never touch the bodies.”
The cleaner says his father died of alcoholism related complications, as did one of the four sweepers who work here. “He died right here, in February,” he says. “We are all alcoholics.”
Late in the evening at the Barabanki mortuary, after everyone but Rakesh and two policemen waiting to take back the body of the dead prisoner have left, Rakesh sits under the Seemal tree and tells me about the things that haunt him. Like how, in 2015, he had to do 26 bodies in a single day after a truck carrying construction workers fell into a river. How he lay them out in a row on the ground right here, where we are sitting, and began cutting them up one by one. He started at 4 in the evening and worked through the night.
“I got trapped here,” he says and falls silent. Then he speaks again, in a hushed voice. “I have torn apart children,” he says. “Newborn babies.”
He is interrupted by the two policemen who want him to finish stitching up the body of the prisoner. Rakesh regains his composure and walks briskly to the autopsy room, where he begins rhythmically sewing the body.
“There is a doctor, a surgeon, who was here one day watching me work and he told me that I work just like a surgeon,” Rakesh says, smiling for the first time in the day. “Sometimes I think, how did I get here? How did I become a person who even a doctor says can work like a surgeon?”
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