Abstract
Unexpected death from obscure causes places a responsibility on the coroner which is delegated to the police, the pathologist and the laboratory. Important insurance and civil litigation issues may be at stake and crime must not be overlooked. This article stresses the importance of (a) powers of observation, (b) awareness of possibilities, (c) a flexible mind and (d) competence in forensic pathology. Cases quoted and illustrated show mistakes which have caused error—and injustice.
The importance of discussion with clinical colleagues is emphasized; painstaking autopsy and meticulous laboratory examinations are vital. Poisoning is particularly easily overlooked.