Lessons from the SARS-CoV-2 Pandemic: Perspectives in the Medico-Legal Field

Abstract

Background: The SARS-CoV-2 pandemic led to an enormous global health, social and economic crisis. The pandemic caused considerable upheaval and considerable difficulties due to an unforeseen and devastating health condition. Materials and Methods: We discuss the numerous challenges encountered in the fields of forensic medicine and public health during the COVID-19 pandemic. Particularly during the first wave of the pandemic, forensic pathologists faced significant difficulties due to the lack of safe autopsy protocols and insufficient personal protective equipment. Mainly in Europe, they had to manage a substantial number of potential cases of medical liability related to COVID-19. The widespread outbreak of the virus in residential care homes and prisons posed another significant challenge. Furthermore, forensic pathologists had to address the issue of complications arising from vaccination campaigns. Conclusions: This article underscores the need for continued efforts in scientific research and healthcare preparedness to effectively manage such complex crises. Forensic pathologists must be equipped with the necessary resources and training to address unpredictable, complex situations with far-reaching social implications.

1. Introduction

The SARS-CoV-2 pandemic has led to a huge global health, social, and economic crisis. The latest scientific articles report more than 765 million cases of COVID-19 worldwide with related death tolls [1,2].

The World Health Organisation (WHO) declared the start of the pandemic on 11 March 2020 [1]. This pandemic has caused rapid spread of the disease, mortality, social isolation, economic problems, and even political unrest. In addition, the significant increase in COVID-19 cases has created an unprecedentedly severe global health situation, resulting in an urgent need for hospital facilities to treat infected patients [1].

The pandemic has ignited a robust debate, often characterised by conflicting viewpoints. Mass media communication on the issue has occasionally been superficial, contributing to public confusion [3].

Infection has shown an age-related risk gradient and increased mortality due to the presence of several comorbidities [4]. In general, the infection fatality rate was about 0.15–0.23%, although higher and lower estimates have been proposed [4,5,6,7,8].

Especially in 2020 and also in the early phase of 2021, healthcare systems were overwhelmed by viral pneumonia cases with a high number of critical and rapidly fatal cases [9].

The pandemic has shown the unpreparedness of hospitals to cope with unpredictable and chaotic situations. Lack of beds, adequate isolation spaces, personal protective equipment, ventilators, and insufficient health and medical staff were common problems in many countries. Physicians specialised in other disciplines were assigned to COVID-19 wards and have been responsible for the care of these critical patients [9].

In addition to the problems directly related to the pandemic, indirect problems have also emerged, including anxiety and concern due to COVID-19, and the effects of the lockdown have also led to an increase in mental health difficulties [10].

International organisations and fervent scientific research played an important role in coordinating efforts to counter the SARS-CoV-2 pandemic [1]. In fact, about a year after the pandemic, the vaccination campaign started almost worldwide with enormous clinical and prognostic results [4].

After the initial trust and reliance on the institutions and medical personnel, the population showed impatience with the restrictive measures and even partial scepticism to vaccination. The latter played a fundamental role in overcoming the pandemic and reducing mortality; however, part of the population did not fully understand the efforts and work of the scientific community and also seemed to have forgotten the recent past and the severity of the pandemic.

It was only on 5 May 2023 that the WHO declared that COVID-19 was no longer a global health emergency [1].

Almost a year after the end of the global health emergency, what has been the lesson? It is difficult to answer this question, but perhaps it has already been forgotten, in view of the fact that investments in the health system in some countries do not seem to be fully satisfactory. The participation and awareness of the population also seem to have declined. The words of the Director of the WHO that the next pandemic is not a question of if, but when, resound in this regard.

2. The Lesson of the Pandemic in the Medico-Legal Field

The pandemic also had considerable and even dramatic impacts on the field of forensic medicine and forensic pathology.

Numerous studies have investigated the persistence of SARS-CoV-2 in post-mortem cadavers [11,12,13]. According to multiple scientific studies, SARS-CoV-2 can persist in cadavers for extended periods post-mortem, up to 12–13 days [14,15]. However, the detection of SARS-CoV-2 genetic material at low viral loads, without evidence of viral replication, cannot be considered indicative of an active infection, and therefore the cadaver should not be considered “infectious” [16].

With regard to autopsy practice, some countries (such as some Italian centres like Genoa) had an insufficient number of ‘safe’ autopsy rooms, and the number of autopsies decreased. In fact, in the first months of the pandemic, the possible transmission of the disease via an infected cadaver had not yet been studied in scientific studies. For this reason, only external examinations were performed in cases of established or suspected infection due to insufficient protective measures. Obviously, this limited autopsy studies on SARS-CoV-2 pathology, mainly during the first months of the pandemic. Subsequently, molecular nasal swab screening tests were introduced and many reference centres were provided with safe environments (BSL3 autopsy suite associated with adequate personal protective equipment [17]) as a consequence of investments in healthcare. However, the forensic pathologist was faced with a difficult situation during the first phase of the pandemic due to inadequate security measures (reduced number of safe autopsy rooms and reduction of personal protective equipment) and poor scientific knowledge about COVID-19.

Another issue of close medico-legal interest was the widespread spread of SARS-CoV-2 infection in residential care homes [18]. Here, the disease affected elderly and frail patients with a high mortality rate. For example, according to an authoritative study [19], the mortality rate was higher for elderly living in a residential setting (19.3%) than those living at home (13.0%). The considerable infection in these facilities was due to organisational deficiencies and the lack of adequate prevention measures. Especially during the first phase of the pandemic, residential care homes did not have sufficient space to isolate infectious patients and personal protective equipment was scarce. The widespread of the virus in residential care homes for the elderly was investigated by criminal justice offices in Italy such as Genoa. The aim was to find out whether the infections were due to an unavoidable spread of the virus or related to healthcare malpractice. In these cases, the medical examiner was faced with a particularly complex task, having to provide an opinion by studying the health documentation (often deficient and incomplete) and keeping in mind the unexpected and disruptive situation and therefore the considerable difficulties in dealing with it. These cases were not followed by criminal convictions as the contagion, which was certainly due to poor sanitary conduct, was difficult to prove. The severity of the pandemic and the objective difficulties in counteracting the contagion made the viral spread possible even with the best application of containment measures.

The pandemic has brought uncertainty regarding liability risks for healthcare workers (HCWs). These include the breaching of standards of care, criminal liability and negligence claims, the breaching of privacy and confidentiality, resource allocation, etc. [20]. Many countries have focused on the need and importance of legal protections for HCWs [20]. An extremely difficult situation has been addressed: a fair balance between protecting the liability of health workers and the need to sanction health facilities and staff who are responsible for inadequate management [21].

In this regard, an important issue was the management of non-COVID-19 patients, especially in the oncological field. Apart from the emergency and urgent conditions, medical personnel found themselves in a difficult situation: on the one hand, the need to treat/investigate the pathology (as in the case of cancer), and, on the other hand, the need to reduce the risk of infection (e.g., by postponing any immunosuppressive therapy and reducing hospital exposure) [22]. The physician therefore had to carefully weigh the therapeutic benefits against the possible risks in order to avoid being accused of not treating the patient well or of exposing the person to the risk of infection. Moreover, many patients (even if they were ill) were afraid to enter a hospital because of the risk of nosocomial contagion. In fact, during the pandemic, many diagnoses of COVID-19 were reported during hospitalisation. This issue increased the number of medico-legal litigation with claims to hospitals [23]. In order to avoid overestimation of costs and expenses, the medical examiner was faced with a difficult task, i.e., to understand whether the infection was really contracted in the hospital or whether it was acquired in the community and incubated at the time of hospital admission.

Within the public health sphere, the spread of infections during detention (particularly in overcrowded conditions) poses a significant challenge. Many prisons had a significantly larger inmate population than their rated capacity and a universal consensus on how to manage overcrowding in prisons was not shared [24]. This situation undoubtedly increases the risk of contagion exponentially. Such circumstances could also potentially lead to medico-legal disputes.

Providing personal protective equipment to staff, improving sanitary conditions, screening the population, isolating and monitoring suspected cases, and ensuring access to vaccination among inmates were all fundamental state strategies to limit the spread of infection [24]. It is crucial to remember that prisons are not isolated from communities and the health of the community has a direct impact on prison environments [25]. Consequently, detention systems must maintain high levels of hygiene, expand and improve spaces, and ensure readily available access to all necessary resources (personal protective equipment, vaccines, etc.) for the health and care of inmates.

The pandemic has also posed severe problems for the management of the morgue. In many centres, the number of deaths has exceeded the number of available places and the capacity to correctly manage the corpses. This fact has created great difficulties for the physicians in charge of the morgues. The relatives could not always observe the body (sometimes behind a plexiglass) and were not allowed to touch the deceased [26,27,28]. The situation was very complex, as the relatives had not only lost a loved one but could not say goodbye as they would have liked. To overcome these difficulties, a careful, empathetic conversation was necessary to explain that all the limitations were aimed at ensuring the health of the relatives. Furthermore, the morgue workers found themselves having to manage an overload of work, and accurate training and information (also on the correct use of personal protective equipment) were necessary to ensure biosafety.

Last but not least, even cases of fatal complications (myocarditis, thrombosis, thromboembolism) have been reported following the administration of both mRNA-based and adenovirus-based COVID-19 vaccines [29,30,31,32,33,34]. In several cases, the public prosecutor initiated investigations and requested autopsies. The forensic pathologist was faced with a difficult task: on the one hand, to perform a complex examination in an area that was still poorly understood, and on the other hand, to understand whether there had been medical malpractice. In the latter area, the most important aspects were the correct anamnestic collection, the information given to patients about the possible risks and adverse events of the vaccine, and the presence of contraindications to vaccine administration [35].

Moreover, the correct diagnosis and correlation between acute pathologies and vaccination have represented a great responsibility for forensic pathologists, with a great media impact.

In conclusion, the pandemic caused considerable upheaval and difficulties even in the medico-legal field due to an unforeseen and devastating health condition. Forensic pathologists had to work in complex, difficult, and unfamiliar conditions. This was due to a lack of safe autopsy rooms, insufficient personal protective equipment, and also a shortage of personnel and resources. In addition, they had to manage and evaluate all possible cases of medical malpractice related to COVID-19. The hope is that this pandemic was a severe lesson to bear in mind for the future. For all these issues, the solutions have a common denominator: invest in healthcare in the medico-legal context as well. Every hospital will have to be equipped with adequate hospital spaces and personal protective equipment and tools, and the role of the medical staff will have to be central to the implementation of recruitment in order to avoid an insufficient number of staff with excessive shifts and inevitable difficulties in providing high-level services. Even with these measures, a reduction in cases of potential medico-legal litigation will be possible [23].

From the point of view of forensic pathology, health systems will have to provide facilities (i.e., safe autopsy rooms) and modern instrumentation, implement analytical laboratories (e.g., histology and toxicology laboratories), and foster scientific research with constant refresher courses.

Autopsy studies also have great implications in the clinical sphere: through necropsy, it is possible to learn more about a pathology, understand the pathophysiological mechanics, and, consequently, understand the fundamental aspects for generating a therapy and preventing the disease.

The scientific community and governments must continue to work together to improve healthcare facilities and services through the necessary investments. In the future, only by remaining aware, through international collaboration and continued investment in healthcare (including forensic and scientific research) can such serious and dramatic new scenarios be avoided.

In such an unstable international situation, with the possibility of new pandemics, the forensic pathologist must be put in the best possible position to deal with unpredictable, complex situations with a major social impact.