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Review

Post-COVID-19 Era Forensics: Hospital Autopsies, New Methodologies, and Medicolegal Perspectives

by
Simona Zaami
1,
Gabriele Napoletano
1,
Enrico Marinelli
2,
Sara Sablone
3,
Lina De Paola
1,* and
Francesco Introna
3
1
Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University, 00161 Rome, Italy
2
Department of Medico-Surgical Sciences and Biotechnologies, “Sapienza” University of Rome, P.le A. Moro 5, 00185 Rome, Italy
3
Department of Interdisciplinary Medicine, Section of Legal Medicine, Bari Policlinico Hospital, University of Bari, Via Orabona 4, 70126 Bari, Italy
*
Author to whom correspondence should be addressed.
Forensic Sci. 2025, 5(1), 8; https://doi.org/10.3390/forensicsci5010008
Submission received: 28 October 2024 / Revised: 18 January 2025 / Accepted: 4 February 2025 / Published: 12 February 2025
(This article belongs to the Special Issue Post-COVID-19 Era Forensics—the Advantages and Challenges of Digital Transformation)
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Abstract

:
Background: Hospital autopsies, once considered fundamental to evidence-based medicine, have declined in many Western countries due to legislative changes, faith-based objections, and inadequate funding in public healthcare. However, the COVID-19 pandemic has revitalized interest in their importance for determining the cause of death and generating public health statistics. This study analyzes the factors contributing to this decline, with a focus on the Italian context and the new medicolegal perspectives arising in the post-pandemic era. Methods: The research was conducted through an analysis of 91 relevant scientific sources, including government documents, policy briefs, and academic studies. Legislative and regulatory factors influencing the reduction in hospital autopsies were examined, along with new technological and medicolegal perspectives that have emerged following the COVID-19 pandemic. Special attention was given to the Italian context and the pandemic’s impact on autopsy practices. Results: The analysis revealed that the perceived “low value” of autopsies often stems from technological advancements, which have led to the view of these procedures as redundant. However, in the post-COVID-19 era, there has been a renewed awareness of the medicolegal value of autopsies, with significant implications for public health statistics and the evolution of forensic medicine. Conclusions: The COVID-19 pandemic highlighted the vital role of autopsies in delivering accurate medical information, prompting renewed attention to these procedures in the post-pandemic era. Moving forward, hospital autopsies will need to balance technological innovations with traditional medicolegal practices, paving the way for new perspectives in forensic medicine and public health data management.

1. Introduction

Hospital autopsies require specialized expertise and well-equipped facilities. Despite their foundational role in evidence-based medicine, autopsy rates in hospitals have significantly declined [1]. This trend stems from factors such as legislative changes, faith-based objections, limited public healthcare funding, and improved diagnostic technologies [2]. Additionally, pathologists, burdened by daily diagnostic tasks, show decreasing interest in performing autopsies, which are often perceived as having “low value” due to medical advancements.
However, autopsies remain the gold standard for determining the cause of death and are crucial for accurate public health statistics. Their decline threatens proper disease funding, medical education, and diagnostic quality. Autopsies also provide critical tissue and fluid samples for diagnostics and personal identification [3,4]. To revitalize their role, standardized evidence-based guidelines are needed, along with the integration of advanced technologies to enhance autopsy procedures [5].
The term “autopsy” derives from the Greek word αὐτοψία, which literally means “to see with one’s own eyes”. It is composed of αὐτός (“same”) and ὄψις (“sight”), thus giving the term the meaning of “vision and direct knowledge of the facts” as a source of information. In this sense, the term was first used by the Greek historian Herodotus [6]. Over the centuries, it began to be employed in medicine to refer to the examination conducted on a corpse, based on eyewitness testimony, which served to identify the manner and cause of death.
Since the times of the Egyptians [7] and ancient Greece [8] up to the Roman Empire, autopsies have always been performed. It is worth noting that although the circumstances surrounding Julius Caesar’s death are mostly known, we can assert with certainty—thanks to the doctor Antistius—that despite the twenty-three stab wounds, death occurred due to a dagger strike at chest level. Over the centuries, the value of autopsies as a source of knowledge grew enormously, thanks to many scientists [9]; however, it was only in the early decades of the 19th century that autopsies began to gain greater significance in the medical scientific field [10,11].
At the beginning of the 20th century, the Commission for Hospital Accreditation (JCAH) was established in the USA [12], which set a minimum autopsy rate (at least 20% of the deceased) to ensure and improve the quality of hospital care and to provide more accurate epidemiological data on the cause of death. Therefore, after centuries of performing autopsies in ever-increasing numbers—especially due to the growing scientific curiosity that distinguishes human beings—recent decades have witnessed a reversal of this trend. Perhaps due to the advent of new diagnostic methods and the increasingly accurate and specific knowledge of pathologies, the role of autopsies has gradually diminished.
Moreover, advancements in technology have introduced alternatives to traditional autopsies, such as verbal autopsies and virtual autopsies. Verbal autopsies are conducted through interviews with family members and healthcare providers to gather information about the deceased’s health and the circumstances that may have led to death, while virtual autopsies utilize imaging techniques, such as computed tomography (CT), to analyze the body without invasive surgical procedures [13]. These new methodologies offer valuable insights in some cases, but they fundamentally differ from the direct hands-on examination provided by traditional autopsies, raising questions about the future role of autopsies in general medical practice and the role of forensic medicine. While these approaches have merit, they lack the comprehensive insights of traditional autopsies, raising concerns about their adequacy in forensic and medical contexts.
Therefore, the article aims to assess the importance of autopsies and their renewed value, thanks to the scientific data provided during the pandemic, across different countries in the Western world, as well as in light of new technologies available to medicine.
The COVID-19 pandemic has reignited interest in autopsies, regarded as a valuable tool for providing epidemiological data and addressing the challenges posed by emerging diseases. This article examines the renewed relevance of autopsies, highlighting their role during the pandemic in various Western countries and exploring how new technologies can integrate with traditional practices. Through these themes, the research aims to clarify the evolving role of autopsies in modern medical and forensic science, particularly in the post-pandemic era.

2. Materials and Methods

We analyzed papers published and available on PubMed over the past five years, from 2020 to 2024, using the search terms “Hospital autopsy AND COVID-19 AND forensic pathology”. The database search yielded 118 records. Articles identified through databases were screened by title and abstract. The full texts of potentially relevant articles were then analyzed and reviewed to assess their eligibility. Duplicates and papers focused on forensic issues were excluded. Only articles in English were included. We included all types of papers, from case reports to reviews, without any exclusion criteria, to ensure our work was as comprehensive as possible. Cases involving both sexes (M/F) were considered. Ongoing studies were not included in the analysis. In the end, 82 records remained that aligned with the research aim. Additional data were incorporated into the study after manually searching websites and organizational documents to better understand the focus of the study. Ultimately, as can be seen in Figure 1, 91 sources were deemed suitable for inclusion in this review. The aim of the study is to highlight the factors contributing to the renewed importance of hospital autopsies. In recent years, their value has been rediscovered thanks to the insights forensic dissections have provided into many pathological mechanisms, particularly during the COVID-19 pandemic. Furthermore, the authors found it important to clarify and emphasize how the role of the forensic expert is viewed differently across various countries in the Western world, depending on cultural and legal contexts, and how new technologies have changed the way forensic pathologists work. By addressing these themes, the research seeks to clarify the evolving role of autopsies in modern forensic and medical science, particularly in the post-pandemic era, with a focus on Western countries and specifically Italy.

3. Results

3.1. Autopsy Rates Are Constantly Declining in Western Countries

After a constant increase over the centuries, hospital autopsy rates have been declining for several decades. In the United States, autopsies were performed in 40–60% of all hospital deaths prior to 1970, while the current rate is below 5%. Such a decline is not limited to the United States but is a worldwide trend [14,15]. Similarly, UK autopsy rates went from 25.8% in 1979 to 0.69% of all hospital deaths in 2013 [16]. Figure 2 and Figure 3 highlight how steep such a decline has been for Western European countries in the 2001–2021 period, with Italy’s autopsy rate for hospital deaths declining from 4.5% to 1.5% [17].

3.2. The Issue of Family Consent: Differences Between Countries

Research findings clearly show that family consent has played a decisive role in the decline of hospital autopsy rates. In some countries, this has had a “devastating effect”, causing a sharp drop in autopsy activity, as seen in France [18,19]. Many nations, including France (Law No. 94-653 of 29 July 1994) [20], Germany (KHSG Law, 12 October 2015) [21], the UK (Human Tissue Act, 2004 [22]), and Spain (Law 29/1980) [23], require next-of-kin authorization for autopsies [24]. However, in countries such as Italy, Austria, and several Eastern European nations, post-mortem examinations remain solely a medical decision [19,24].
In the United States, the management of corpses and human remains is governed by Common Law principles [25,26]. Upon death, custody of the remains passes to the next of kin, typically starting with the surviving spouse. This individual is responsible for ensuring proper disposal of the remains and may authorize an autopsy or donate the body for therapeutic or educational purposes [24,25,26,27,28]. While not all U.S. jurisdictions specify a strict hierarchy for obtaining consent, many follow a legal order based on Common Law or the Code of Succession. For instance, in California, the hierarchy includes the surviving spouse, surviving child, surviving parent, and next of kin.
According to California Government Code 27520, the coroner may perform an autopsy if requested in writing by the highest-priority relative, starting with the surviving spouse [29,30,31]. Like other Western countries, the U.S. has seen a steep decline in hospital autopsy rates, dropping from 50% in 1940 to just 4% in 2018 [32].

3.3. COVID-19 and Autopsies in Italy

In Italy, the Mortuary Police Regulation is the regulatory instrument that defines the link between autopsy activities and each local authority. Such a connection plays a role for autopsies of all types as follows:
  • Judicial (local jurisdiction);
  • Hospitals (organization by company);
  • Checks on deceased subjects with no healthcare coverage (local health authority).
In Italy, various pieces of regulation and targeted recommendations have been issued for the purpose of governing autopsies in COVID-19 victims. At the onset of the COVID-19 pandemic in Italy, autopsies were significantly reduced and, in some cases, suspended for safety reasons. This measure was implemented in accordance with the national and international health authorities’ recommendations, aimed at minimizing the risk of exposure to the virus for medical and forensic personnel.
The few autopsies performed at the beginning were conducted only in facilities that met specific criteria and adhered to strict safety and preparedness standards [33]. The most relevant sets of standards issued to govern autoptic exams over the course of the pandemic emergency have been succinctly outlined in Table 1.
At the start of the COVID-19 pandemic, autopsies were limited due to strict selection criteria, hospital safety requirements, and a lack of facilities with BSL-3-compliant negative-pressure autopsy rooms. While autopsies were crucial for understanding the virus’s pathogenesis, many deaths attributed to COVID-19 were not fully examined, leading to an initially incomplete understanding of its effects on organs [39] Advanced personal protective equipment (PPE) was mandatory for medical and technical personnel, including airtight protective suits, FFP3/N95 masks, protective goggles or, preferably, face shields and double gloves, which were not always available [40].
The limited number of autopsies during the early pandemic was due to stringent sanitation protocols, the need for segregated pathways for transporting bodies, and a lack of facilities meeting advanced biosafety standards. Logistical challenges, hospitals’ focus on critically ill patients, and the overwhelming workload contributed to underestimating the importance of autopsies. Healthcare workers, under immense pressure and sometimes facing verbal and physical aggression, further exemplified the strain on the system [41,42].
Italy, as the first European country to face the SARS-CoV-2 virus, encountered significant challenges in its public healthcare system’s readiness and response. Despite the limited number of autopsies, those that were performed provided critical insights, revealing complications such as massive thrombosis and disseminated intravascular coagulation (DIC) [43,44], leading to changes in treatment protocols, including the use of anticoagulants. These autopsies also highlighted that COVID-19 was not just a respiratory disease but one with multi-organ impacts and widespread inflammation [45,46,47]. Autopsy recommendations were periodically updated based on new findings and guidance from organizations like the WHO, CDC, the Ministry of Health, and the ISS [48,49]. In conclusion, although the restricted use of autopsies in the early stages was necessary to protect healthcare workers and prevent virus transmission, it has faced significant criticism. Nonetheless, the few autopsies conducted played a crucial role in shaping treatment strategies and public health policies.

3.4. Forensic Doctors and Hospital Autopsies: Europe vs. USA

Debate in Italy has long focused on whether forensic doctors can perform hospital autopsies. Legally, the answer is affirmative provided the hospital has suitably equipped forensic medicine facilities. No legislative changes are required, as current regulations (Presidential Decree No. 285/90, Art. 37, Para. 3) already allow medical directors to assign autopsies to anatomical pathology specialists or other medical professionals for diagnostic purposes. Additionally, the New Essential Levels of Care (LEA) [34] include medicolegal activities, such as autopsy services, under the framework of collective prevention and public health.
In other countries, in recent decades, there have been significant changes in the number of hospital autopsies. Whereas in 1972, autopsies of deaths due to illness accounted for 79%, those due to external causes was 19%, and those due to indeterminable conditions was 2%, in recent years, the latter two causes have exceeded 50% of all autopsies [50]. This phenomenon has been accompanied by an increase in difficulties in meeting the minimum requirements of the pathology training program. There has been an increase in the number of autopsies aimed at investigating possible iatrogenic damage, civil liability, or the involvement of insurance companies with a preference for predominantly forensic expertise [51,52].
Clinical misdiagnoses that go undetected can prevent errors from being corrected through autopsies. A retrospective review at the University of Vermont Medical Center of 1097 cases found diagnostic errors in 2.1% of cases, which contributed to patient deaths [53]. This suggests that lives could have been saved and highlights the ongoing value of autopsies. Additionally, a U.S. study of 551 autopsies in hospital deaths leading to litigation found that autopsies provided clear diagnoses in 21% of cases, unexpected diagnoses in 50%, supported the defense in 55%, and harmed it in 27% [54].
Studies on medical malpractice insurance suggest that autopsies provide limited additional information for resolving legal cases [52,55]. However, a recent German study highlights their educational value, noting that in emergency settings, major errors occur in 37% of cases, with potentially avoidable deaths in 12.4% [56]. In regions of the UK with few pathologists, post-mortem computed tomography (PMCT) has shown promising results in determining the cause of death [57]. While radiological investigations can quickly provide valuable insights, detailed autopsies remain crucial in specific contexts. Hospital and forensic autopsies are especially important in pediatric, fetal, and perinatal cases. According to a multicenter prospective study, these complex autopsies—averaging 15, 5.9, and 9.8 h, respectively—offer significant clinical value, helping families assess health risks and make informed reproductive decisions [58,59].
By directing doctors towards genetic diagnosis, not only can autopsies be useful to reclassify genetic variants of uncertain origin but also to identify family members who could benefit from very expensive genetic testing or innovative gene therapies. In such a young population, autopsies reportedly have a considerable impact on the health of family members and can provide new diagnostic information in 15–76% of cases [60]. These changes over the years do not seem to diminish the role of the autopsy; rather, they outline new paths for the pathologist or forensic pathologist to follow in the interest of patients and public health. It remains to be seen whether an autopsy can be of any value in cases of sudden death without an obvious history, which could leave room for civil law implications or compensation claims [61]. Bringing clarity to the changes affecting autopsy requests is helpful in reviewing the role of medical examiners. The latter often find themselves handling autopsies of infants or young adults who died suddenly without relying on adequate resources to properly serve justice and public health [62]. In such cases, it is therefore imperative to strengthen multi-specialist collaborations (cardiologists, geneticists, and family doctors) and to have direct contact with family members so that the forensic pathologist can intervene in cases where the health of an entire family may be at stake [63].
The pathologist and forensic physician, through autopsies, can identify fatal genetic or environmental conditions that may affect the deceased’s family members. Sometimes, they may be the only ones aware of cardiac deaths or deaths caused by toxins (such as lead or carbon monoxide). However, their work may be limited by ethical and practical issues that affect the quality of the autopsy. For example, the complexity of reporting criteria and financial or ethical constraints may prevent the request for genetic tests that could be important for the family [64]. In the future, cause-of-death investigations could involve autopsies assisted by a medical geneticist, who could identify serious genetic risks for family members. There is a broad consensus that hospital autopsies are a highly specialized procedure requiring professional expertise and appropriately equipped facilities. Autopsies should be performed by pathologists with expertise, conducting at least 50 autopsies per year, or by supervised trainees [1]. The minimum number of autoptic procedures to be performed in order to be considered an expert in this field varies depending on the country, as can be seen in Table 2.
There is a broad consensus that hospital autopsies still contribute to evidence-based medicine, as they constitute an irreplaceable tool for the training of students, residents, and doctors. In addition, the quality control of public statistics and clinical practice are positively affected as well, as is human tissues research, hence our understanding of complex diseases (e.g., rare diseases, diseases in the field of neuropathology [65], viral infections [66], and collagen vascular disorders [46,67]). The experience shared by the Forensic Medicine of Rostock in Germany can be a concrete model that testifies to the significant value of an early autopsy with direct collaboration in the autopsy room with the forensic pathologist, the pathologist, and the specialists who were treating the patient, in order to figure out the real causes of death and gain feedback on the medical service performed [68].
Table 2. Minimum autopsy requirements in pathology and forensic pathology residency [1,69].
Table 2. Minimum autopsy requirements in pathology and forensic pathology residency [1,69].
CountryPathologyForensic Pathology
Accreditation Council
for Graduate
Medical Education
(United States) [70]		A minimum of 50 autopsy cases including exposure to forensic, pediatric, perinatal, and stillborn autopsies.A minimum of 200 and no more than 300 autopsy cases
Royal College of Physicians and Surgeons of Canada [71]No minimum number of autopsy cases. Accredited programs must have a volume and diversity of work available for teaching that must be adequate to meet the educational objectives of the program, with an adequate number of adult, pediatric, and forensic autopsies.A minimum of 100 completed medicolegal post-mortem examinations including infant, children, and adult, with a wide range of natural and unnatural deaths, and 30% of the cases must be of a complex nature (homicides and criminally suspicious deaths)
The Royal College of Pathologists
(United Kingdom) [72]		Stages A and B (2 years of basic histopathology training) requires 20 adult autopsy cases each year, with a total of two perinatal/pediatric autopsies.Stage C (minimum of 30 months) requires 80 autopsy cases each year; Stage D (minimum of 6 months) requires 50 autopsy cases; also required to complete 3 months of pediatric pathology and 3 months of neuropathology
European Society of Pathology (E.S.P.) [1]The autopsy should be coordinated by a specialist with proven experience and findings should only be performed by specialists in pathological anatomy or forensic pathology/forensics or possibly by specialists in training under direct supervision. Finally, to ensure adequate expertise, there is a minimum number of annual autopsies per individual team member, equal to at least 50 diagnostic findings and annual judicial autopsies.The autopsy should be coordinated by a specialist with proven experience and findings should only be performed by specialists in pathological anatomy or forensic pathology/forensics or possibly by specialists in training under direct supervision. Finally, to ensure adequate expertise, there is a minimum number of annual autopsies per individual team member, equal to at least 50 diagnostic findings and annual judicial autopsies

3.5. What Can Get in the Way of Hospital Autopsies? Does Family Consent Have Any Bearing?

In Italy, the Mortuary Police regulation does not provide for the consent of the family members or close relatives of the deceased to carry out the diagnostic check (and, conversely, nor does it allow for their opposition).
The Gelli law, adding paragraph 2-bis to art. 37 of the Mortuary Police regulation, has introduced the possibility for family members of the deceased patient—in hospital or elsewhere—to “agree” with the medical director on the execution of the diagnostic match and have a legal pathologist of their trust participate in the operations.
Law no. 31, enacted on 2nd February 2006 (“Regulation of diagnostic procedures on the victims of sudden infant death syndrome [SIDS] and unexpected fetal death”), requires a diagnostic check—with the consent of both parents—in the case of the following:
  • Infants who died suddenly within one year of life without apparent cause.
  • Fetuses who died after the twenty-fifth week of gestation, also without apparent cause.
After all, case law reflects the conclusion that corpses are not to be viewed as the property of family members. In fact, as the Supreme Court of Cassation ruled on 19 July 2012 that there is no subjective right of close relatives over the body of the deceased person and hence, no right or power to dispose of it can be ascribed to family members [73].

3.6. If Not Legal, What Reasons for Declining Autopsies? And What of the New Technologies?

There appears to be a widespread belief that modern imaging techniques and laboratory tests are sufficiently reliable for diagnosing diseases and determining the cause of death [74,75,76]. Various surveys among medical professionals have reported that at least 50% of doctors consider autopsy findings to be of little relevance [77,78,79,80,81,82]. However, the risks associated with the sharp decline in autopsy rates have been emphasized by numerous sources, arguing that autopsy has been one of the most powerful diagnostic tools in medicine for over a century. Despite its importance in determining the cause of death and clarifying the pathophysiology of numerous diseases, hospital autopsy rates continue to decline. Studies aimed at assessing the role of counseling and discussions between physicians and families and whether families are more likely to consent to an autopsy following such discussions at the time of death have shown significantly higher consent rates when autopsies were indeed discussed in a timely manner. Interestingly, the primary reason cited by families for refusing consent was the belief that the cause of death was already known [80,81,82]. One of the key factors contributing to the decline in autopsy rates appears to be the development and increasing reliance on new non-invasive diagnostic technologies, which are profoundly transforming the fields of medicine and forensic pathology. Among these, verbal autopsy, virtopsy, and artificial intelligence (AI) are emerging as modern, less invasive alternatives to traditional autopsies [5,76,83].
Verbal autopsy is gaining popularity as a methodology in contexts where resources for traditional autopsies are limited, such as in developing countries [84]. It relies on detailed interviews with the deceased’s relatives and a review of the patient’s clinical history to determine the probable cause of death. Although lacking the scientific precision of a physical autopsy, verbal autopsy is a practical and cost-effective solution for obtaining important epidemiological data in regions where access to post-mortem examinations is limited [85]. However, it does not provide detailed insights into the pathology or the underlying pathophysiological mechanisms, and thus serves more as a supplementary tool rather than a replacement for a medical autopsy [86].
Virtopsy, or virtual autopsy, represents one of the most advanced innovations in forensic science. This technology uses high-resolution radiological imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and sometimes fluoroscopy to examine a deceased body non-invasively [87]. By creating detailed three-dimensional images, virtopsy can identify internal injuries, hemorrhages, fractures, or congenital anatomical anomalies that might not be detected through traditional means [88]. Virtopsy is particularly useful in cases where religious, cultural, or emotional factors make it difficult to perform a conventional autopsy, allowing forensic experts to provide diagnostic answers while respecting certain ethical and religious sensitivities.
Magnetic resonance imaging (MRI) is another advanced tool that, compared to CT scans, provides a better resolution of soft tissues, allowing for the detection of conditions such as heart disease, stroke, or tumors. Post-mortem MRI (PMMRI) is particularly useful in identifying brain abnormalities or internal injuries, offering a more detailed picture of pathological conditions [89].
Another rapidly growing technology that is transforming post-mortem diagnostics is artificial intelligence. AI is enhancing the interpretation of radiological images, including data derived from the virtopsy and pre-mortem clinical examinations. Through machine learning algorithms, AI is able to analyze vast amounts of radiological data, identifying patterns and anomalies that may go unnoticed by forensic pathologists [90]. For instance, AI can help detect micro-ischemia, small tumors, or micro-lesions that might not be immediately visible in standard radiological images. Moreover, AI is contributing to the development of predictive models, used to correlate pre-mortem clinical conditions with the cause of death, thereby improving the overall accuracy of post-mortem diagnosis. Further technological advancements are also transforming the field of autopsy [91]. Image-guided biopsy autopsy, for example, allows pathologists to collect specific tissue samples for histological analysis without performing a full dissection of the deceased body. In addition, post-mortem molecular diagnostics, utilizing genetic and biomolecular techniques, enable the detection of genetic mutations, viral infections, or other underlying pathologies, providing a more comprehensive understanding of the cause of death. These technological innovations, combined with advances in diagnostic imaging techniques such as CT and MRI used in clinical settings, have contributed to the perception that traditional autopsies are of lesser value. Many physicians believe that modern diagnostic tools can provide sufficient answers without the need for a classic autopsy. However, it is important to note that despite these advances, traditional autopsies continue to yield unique information that cannot be fully replaced by these techniques [92]. Physical autopsies remain crucial for understanding the pathogenesis of many diseases, especially in cases of sudden death or newly emerging or poorly understood diseases [93], as was highlighted during the COVID-19 pandemic. It should also be remembered that over the past 50 years, at least sixty diseases have been identified, described for the first time or characterized through autopsy studies. Among these, it is worth mentioning primary cardiomyopathies, Legionella pneumonia, Creutzfeldt–Jakob disease, analgesic nephropathy, and iatrogenic injuries such as pulmonary oxygen toxicity [94,95].

3.7. COVID-19 and the Reasserted Value of Hospital Autopsies

Due to the recent COVID-19 pandemic, autopsies were suspended during the initial months of the emergency. However, over time, autopsy rates returned to pre-pandemic levels. Similarly to what occurred in previous centuries, the need to understand the effects of the novel coronavirus on the human body and the extent of its threat to public health prompted forensic pathologists to increasingly perform autopsies on individuals who had succumbed to COVID-19 [96]. These autopsies proved highly valuable in providing important data regarding the pathogenesis of COVID-19 [97], such as the discovery of pulmonary thrombosis following SARS-CoV-2 infections [43,45,98]. Autopsies were thus essential not only for gaining a better understanding of the disease but also for reducing the risk of viral transmission.
It is also noteworthy that the WHO declared that the bodies of patients who had died from COVID-19 were not generally infectious, although the lungs could still harbor live viruses; this implicitly recognized the importance of conducting autopsies. Even during the pandemic, the WHO issued specific recommendations for the safe management of the bodies of individuals infected with SARS-CoV-2. The medical community concurred that the use of personal protective equipment (PPE) during autopsies was mandatory [49]. The WHO guidelines specified that the bodies of individuals who had died from COVID-19 should be handled according to the procedures used for other deaths due to acute infectious respiratory diseases. However, the guidelines emphasized that live viruses could still be present in the lungs of those who had died from COVID-19, meaning they could remain infectious. Thus, pathologists were required to wear the following: “a scrub suit, a long-sleeved fluid-resistant gown, gloves (either two pairs…), a medical mask, eye protection (face shield or goggles), and boots/footwear protection… a particulate respirator (N95 or FFP2 or equivalent) should be used for aerosol-generating procedures”.
As COVID-19 evolved into a global emergency, its impact on both citizens’ and healthcare workers’ physical and mental health became evident [41,42]. During this time, the value of autopsies was reaffirmed, with a notable increase in their rates over the past year [96]. Autopsies proved essential in understanding COVID-19’s pathogenesis and pathophysiology. In 2020, as healthcare systems battled the novel virus, the importance of hospital autopsies was recognized by both medical professionals and families. While imaging and diagnostic tools provided some insights, autopsies offered the most comprehensive understanding of the disease [75].
In the U.S., despite concerns about infection risks, the urgency to uncover the virus’s mechanisms led to a rise in autopsies [31]. Early findings revealed that COVID-19 was not limited to respiratory damage but affected multiple organs [46]. These insights informed key therapeutic strategies, such as the use of anticoagulants, antiviral treatments, and decisions on invasive ventilation or patient pronation in severe cases. Autopsy findings significantly influenced the development of life-saving treatment protocols and therapies.
These advancements are reflected in scientific publications in the field of anatomical pathology [99], including the development of innovative research areas such as telepathology [100] (similar to telemedicine) [101] and minimally invasive ultrasound-guided autopsies, used to assess the pulmonary and systemic involvement in COVID-19 patients [99], as well as robotic-assisted surgery as a new autopsy method [80]. As previously mentioned, forensic medicine’s perspectives and horizons [98,99,100,102,103,104] have also significantly expanded during the pandemic [105], and this newly acquired knowledge and approach will be extremely valuable [106] should another pandemic emergency arise in the future [43,47,107,108,109].

4. Discussion

The decline in the rate of autopsies in Italy and in the Western world is mostly unrelated to legal constraints and the rights and protection of religious freedom and dignity of the deceased; it seems that the value and usefulness of the autopsy, albeit widely acknowledged over the centuries, has been gradually decreasing, partly due to major scientific discoveries [110]. Over the decades, it was therefore thought that human dissection could not be compared to new diagnostic means in terms of effectiveness and results. The COVID-19 pandemic has instead substantially reinforced the value of autopsies [90] and of human dissection studies in the field of scientific research [111,112]. Professionals who operate in human pathology are fully aware of how the data gained through such channels have been essential in terms of understanding the pathological mechanisms underlying clinical manifestations [46,47,112]. Leaving aside the initial phase of the pandemic, which caught off-guard virtually all of the medical scientific community worldwide, we then moved on to the implementation of objective procedures based on a rigorous methodology which led the scientific community to take important steps [113,114]. In fact, autopsies were always viewed by the scientific community as the gold standard for determining the cause of death, also thanks to their structure based on a rigorous and objective methodology, including external examination, sectorial macroscopic examination, and microscopic examination [44,113].
This study has shed light on the fact that although the number of hospital autopsies has decreased in absolute terms, in recent years (partly due to the COVID-19 pandemic), their quality has increased. Scientific research in fact relies on autopsies to clarify obscure points in the knowledge of human disease. Forensic medicine and autopsies have also become specialized and while some more well-known and thoroughly researched diseases often do not require further autopsy-based validation, autopsies are indeed essential for diseases which are still relatively obscure to science, especially in terms of pathogenesis, pathophysiology, and progression trends [115].
Autopsies continue to provide essential data, particularly regarding rare or newly emerging diseases, and they remain crucial in maintaining high training standards for professionals in the field [116]. The reduction in hospital autopsies could undermine the training of new pathologists, highlighting the need for international collaboration networks among specialized centers to ensure proper training and accurate diagnoses in more complex cases. Moreover, collaboration between pathologists and clinicians remains vital for expanding the knowledge of pathogenic mechanisms that may not be fully understood through forensic practice alone.
Autopsies could further evolve as a valuable research tool, aiding in the identification of new diseases and emerging pathological variants. Therefore, it is crucial to raise awareness among the public and healthcare professionals about the significance of autopsies.
The COVID-19 pandemic has raised significant ethical concerns, particularly regarding the balance between public health and the safety of healthcare and forensic professionals versus the need for comprehensive autopsy examinations. The initial limitation of autopsies, although necessary due to the early “uncertainty” surrounding the pandemic, aimed to reduce the risk of virus exposure for forensic and medical professionals. However, this limitation undoubtedly compromised the timely collection of critical data needed to understand the pathogenic and systemic characteristics of the virus. This situation highlighted the ethical dilemma between safeguarding healthcare workers and the professional obligation to conduct investigations that might have saved lives through a more thorough understanding of the disease’s pathological mechanisms.
Ethical implications further extend to the difficulty of ensuring the accuracy of autopsy diagnoses in the absence of complete examinations, creating gaps and potential risks for justice, especially in cases involving suspicious or contested deaths. The introduction of minimally invasive techniques and remote autopsy methods has sought to address these challenges but, in turn, has raised additional questions regarding the validity and accuracy of the findings. This has, to some extent, eroded public trust in clinical decisions based on such indirect methods. The introduction of new technologies, such as virtual autopsy and post-mortem magnetic resonance imaging (PMMRI), offers promising non-invasive tools. However, these advancements also raise ethical concerns [117]. Issues such as limited accessibility, the potential dehumanization of the process, and legal challenges related to the use of these technologies require careful consideration to ensure they are integrated with traditional methods without compromising ethical or legal standards.

What Can Be Envisioned?

It would be highly desirable at the international level to improve healthcare infrastructures by investing in facilities with appropriate biosafety measures (BSL-3). This would be essential to ensure that comprehensive autopsies can be performed safely during future pandemic emergencies. These improvements should include negative-pressure rooms, dedicated “clean/contaminated” pathways for the transportation of bodies, and the implementation of advanced and internationally recognized sanitation protocols.
Adequate and continuous forensic medical training should be guaranteed, focusing on autopsy methodologies as well as the correct use of personal protective equipment (PPE). It is critical to implement pandemic preparedness plans to ensure that PPE remains consistently available, maintaining the continuity of autopsy investigations even during emergency scenarios. Furthermore, integrating technologies such as post-mortem computed tomography (PMCT) and magnetic resonance imaging (PMMR) is essential. These technologies can provide a safe and non-invasive alternative to traditional autopsies, although conventional methods should remain the preferred choice wherever feasible.
It would also be advisable to establish standardized international guidelines aimed at facilitating the work of forensic professionals and policymakers. Such guidelines would help ensure rapid and effective responses during emergent pandemic scenarios.
An area of particular interest for technological innovation could involve the introduction of artificial intelligence (AI) for the analysis of autopsy images and data. AI has the potential to accelerate diagnostics and improve accuracy. Advanced software could identify patterns in biometric data that might otherwise go unnoticed by the human eye, thereby enhancing the understanding of diseases. However, this must be accompanied by strict safeguards to ensure the privacy of healthcare data, a concern that is not always straightforward when dealing with AI technologies.

5. Conclusions

In summary, despite the decline in the number of autopsies in recent decades, their role remains crucial in both clinical practice and scientific research. The COVID-19 pandemic has reaffirmed the importance of autopsies in understanding complex pathologies, highlighting the need to maintain high-quality training for pathologists and forensic specialists. International and interdisciplinary collaboration can enhance diagnostic accuracy and improve healthcare outcomes.
The adoption of new technologies, such as virtual autopsies and post-mortem magnetic resonance imaging, offers promising opportunities but requires careful ethical and legal consideration to ensure proper integration with traditional methods. Raising public awareness of the value of autopsies is essential, leveraging the expertise gained during the pandemic is necessary, and avoiding the repetition of mistakes made during the COVID-19 pandemic is crucial. Establishing international guidelines for emergency situations is imperative for medical progress and public health improvement.

6. Limitations

Our study presents clear limitations. The research is primarily based on data collected from PubMed and a limited selection of keywords, which, while effective, may have excluded relevant articles on the topic. Additionally, our focus is largely centered on Western countries, particularly Italy, and within the context of the COVID-19 pandemic. This implies that the global perspective on autopsy practices may not have been fully explored. Forensic autopsies were not considered in our study, only hospital-based autopsies. We introduced the role of emerging technologies, such as virtual autopsies and artificial intelligence; however, due to the scope of the article, we were unable to thoroughly explore their broader implications, such as costs, accessibility, and ethical concerns. Similarly, while the pandemic context provided valuable insights, it may limit the generalizability of the conclusions to other medical conditions. These limitations, however, represent a starting point for future research that can expand upon and address the broader issues raised.

Author Contributions

Conceptualization, S.Z. and F.I.; methodology, L.D.P., G.N., S.S. and E.M. software, G.N. and L.D.P.; validation. S.Z. and F.I.; formal analysis, G.N., S.S. and L.D.P.; investigation, G.N., S.S. and L.D.P.; resources, E.M. and S.Z.; data curation, L.D.P., E.M. and F.I.; writing—original draft preparation, L.D.P., G.N. and E.M.; writing—review and editing, F.I. and S.Z.; visualization, S.Z., G.N., E.M., S.S, L.D and F.I.; supervision, E.M., and S.Z.; project administration, S.Z. and L.D.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. PRISMA chart.
Figure 1. PRISMA chart.
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Figure 2. Autopsy rate (%) per hospital deaths updated in September 2022. Source: European Health for All Database [17]. In red, the individual countries; in blue, associations or unions of countries.
Figure 2. Autopsy rate (%) per hospital deaths updated in September 2022. Source: European Health for All Database [17]. In red, the individual countries; in blue, associations or unions of countries.
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Figure 3. The 2001 rates of hospital autopsies per hospital deaths. Source: European Health for All Database [17]. In red, the individual countries; in blue, associations or unions of countries.
Figure 3. The 2001 rates of hospital autopsies per hospital deaths. Source: European Health for All Database [17]. In red, the individual countries; in blue, associations or unions of countries.
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Table 1. Regulation and guidance governing autopsies in COVID-19 victims.
Table 1. Regulation and guidance governing autopsies in COVID-19 victims.
RegulationIssuing InstitutionRelease DateMost Relevant Indications
Circular no. 11392 [34]Ministry of Health1 April 2020During the emergency phase, autopsies and diagnostic tests should not be conducted on confirmed COVID-19 cases, regardless of whether death occurred in the hospital or at home.
SIMLA letter to the Minister of Health [35]Italian Society of Forensic Medicine4 April 2020 (signed by
President Prof. Zoja
and the Secretary-General Prof. Di Mauro).		A request is made to restructure and adapt autopsy rooms nationwide to meet BSL-3 standards or, at a minimum, to upgrade at least one autopsy room in each provincial capital municipality to comply with the essential technical requirements.
Emergency Circular no. 15280
[36]		Italian Ministry of Health2 May 2020Throughout the emergency phase, autopsies and diagnostic tests must not be performed on confirmed COVID-19 cases, irrespective of whether death occurred in a hospital ward or at home.
Circular no. 18457 [37]Ministry of Health28 May 2020.Previously issued Ministerial Circulars did not aim to prohibit autopsies but only recommended limiting them to safeguard the health of healthcare workers and auxiliary personnel.
SIMLA/Italian Society of Forensic Pathologists (GIPF) Communique [35]Italian Society of Forensic Medicine, signed by Prof. C. Campobasso and G Di Vella4 June 2020The lack of anatomical biocontainment rooms required to ensure the proper execution of autopsy activities across the country, as well as the safety of healthcare professionals and mortuary staff, represents a critical issue that must be addressed.
Circular no. 818 [38]Ministry of Health11 January 2021The document no longer includes language “advising against” the execution of autopsies on COVID-19 subjects, effectively lifting the previous restrictions on conducting clinical-forensic autopsy examinations.
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MDPI and ACS Style

Zaami, S.; Napoletano, G.; Marinelli, E.; Sablone, S.; De Paola, L.; Introna, F. Post-COVID-19 Era Forensics: Hospital Autopsies, New Methodologies, and Medicolegal Perspectives. Forensic Sci. 2025, 5, 8. https://doi.org/10.3390/forensicsci5010008

AMA Style

Zaami S, Napoletano G, Marinelli E, Sablone S, De Paola L, Introna F. Post-COVID-19 Era Forensics: Hospital Autopsies, New Methodologies, and Medicolegal Perspectives. Forensic Sciences. 2025; 5(1):8. https://doi.org/10.3390/forensicsci5010008

Chicago/Turabian Style

Zaami, Simona, Gabriele Napoletano, Enrico Marinelli, Sara Sablone, Lina De Paola, and Francesco Introna. 2025. "Post-COVID-19 Era Forensics: Hospital Autopsies, New Methodologies, and Medicolegal Perspectives" Forensic Sciences 5, no. 1: 8. https://doi.org/10.3390/forensicsci5010008

APA Style

Zaami, S., Napoletano, G., Marinelli, E., Sablone, S., De Paola, L., & Introna, F. (2025). Post-COVID-19 Era Forensics: Hospital Autopsies, New Methodologies, and Medicolegal Perspectives. Forensic Sciences, 5(1), 8. https://doi.org/10.3390/forensicsci5010008

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