2018 was a year of many events for forensic pathology in Ghana, from pathologists reportedly refusing to release pathology reports on high profile cases, necrophiliacs being interviewed on TV as celebrities  and going further to recount their sexual encounters with the dead, mortuary attendants taking photos of celebrity decedents and finally threatening to go on strike, I must say that if you are a pathologist in Ghana, one does feel thin, ‘like butter spread over too much bread’. At this rate soon the entire pathology service, granted there was one, will be on its knees with our mortuaries filled with not just dipsomaniacs but necrophiliacs who will be the stars of TV shows. 2019 has also had its own share of controversy, the most recent being the investigation into the death of the ‘Takoradi girls’. The case has become rather complicated with a dizzying maze of events occurring in quick succession with a nearly conclusive outlook in recent time, a departure from the lethargy, confused and almost lost outlook that characterized the investigations at the start of the saga.  The police are at the center of all this and ‘open media courts’ are handing over verdicts by the hour with the number of discussions increasing at breakneck speed. Indeed, it is difficult to keep up. On one such program it was revealed by a panelist that 12 people had been murdered in one week. As a bystander, these are worrying developments, the confusion does not allow one to trust the ‘system’, that is, whatever remains of it if there was ever one.

For proper forensic investigations to be carried out into a suspected criminal death, several key experts are needed. These include forensic scientists (DNA experts, finger print specialists, crime scene investigators, ballistic experts, forensic psychologists etc) police detectives and forensic pathologists (skilled in forensic anthropology, forensic entomology or independent experts in these fields etc).  These experts are held together by a dedicated forensic service run by the medical examiner. The other supporting members of this team include the district attorney and the Medical Examiner / Coroner (magistrate) who issues mandates/warrants for autopsies, arrests and searches in relation to investigations. This team must be a cohesive team that has the sole aim of finding the truth and helping courts adjudicate cases. To do this, they deploy the most sophisticated scientific methods known in forensic science and pathology to obtain evidence that can be used as a basis for making arguments/opinions in a court of law. These arguments ultimately form the basis of legal decisions. Their success depends on working together as a team and knowing each other’s every move. Loopholes are sealed when they work together to answer pertinent questions asked by experts. I hope through this short narration I have made it clear that to obtain quality, a dedicated, parallel forensic service is crucial. This dedicated forensic service is the only way of obtaining the coordinated and systematic approach required for investigating criminal deaths in any country. In such a system, team members go to work thinking about only the cases they are investigating and are going to prosecute, they spend all their time either collecting evidence from crime scenes or bodies ( also a crime scene in essence ) and making sure that culprits are linked in a scientific way to these crimes. If they are not in the field/ laboratory solving a crime, then they will be in court explaining why they arrived at a certain conclusion.  This type of service is what is known as the MEDICAL EXAMINER’S OFFICE or the CORONER’S/CORONIAL SYSTEM in Europe and North America. Now let’s look at the current situation in Ghana.

 

Ghanaians are renowned for loving their dead and I am aware that decedents who had little or no financial support alive may well be the ones that get grand funerals after death. The sudden proliferation of mortuaries and funeral homes albeit without regulation is evidence of our apparent love for the dead. I dare say there soon will more mortuaries and funeral homes than hospitals in this country. As a pathologist however, it is my opinion that this so-called love of our dead does not translate into respect for the dead. Some other countries love their dead even more and will go to all lengths to give them a deserved transition. They will stop at nothing to know why a decedent died and who or what was responsible for that death lest the same fate befalls them. In Ghana, I believe many are interested in the social events of a funeral but the dead person at the center of such an event only gets used as a vessel for the social interaction. I say this because the support services that are available for deceased individuals in Ghana has received no attention since our ‘colonial master’ left us the Coroner’s Act of 1960.  We are still dependent on the same Coroner’s Act they left us with little change to it after 59years. It is going to reach retirement age this year and then maybe we will retire it and work on a brand-new second hand one. Interestingly, like many other neglected things in this country those cursed with making them work are the ones that are blamed when the thing fails to work. The politicians shout and fret then the talkers in the legal system make threats and the police get ordered around and then the pathologist gets everyone blaming him and calling him names on radio, TV and in print. The entire process is a nightmare and nothing like the CSI shows we love to watch on TV or the coordinated work that goes on at dedicated forensic services elsewhere.

 

Presently, deaths due to accidents, suicides, homicides, poisoning or deaths with unknown cause (suspected to be unnatural deaths) require forensic autopsies and are dealt with at government hospitals because there is no other dedicated place to deal with them. The Act that guides the investigation of such deaths is the CORONER’S ACT of 1960. The Act spells out all the circumstances under which a death must be investigated and what must be done under such circumstances. The Act states that these forensic autopsies are to be done by registered medical practitioners (not forensic pathologists). This is the case because there is no dedicated forensic service to deal with these cases and obtaining a pathologist to do one of these cases was a difficult to find luxury outside of Accra in 1960. Unfortunately, the situation has not changed much with Ghanaians demonstrating only contempt for doctors who opt to specialize in pathology, many young doctors will rather specialize in any other specialty other than pathology if only to avoid being rejected by their parents or being called witches and wizards by their families. Anyway, the few trained pathologists have large clinical burdens in diagnostic histopathology and in the Universities and thus carrying out forensic autopsies is second on the list of important things to do. The situation is the same for the busy registered medical officer in the district hospital. Living patients first. A dedicated forensic pathologist will however have no other responsibility but that of carrying out such autopsies. He is employed to do just that at the medical examiner’s office. The matter of well-trained experts to handle challenging forensic pathology cases makes it even more urgent to have such a service. Imagine the mess that was created some years ago when a quack pathologist in one hospital kept attributing deaths of women to someone sucking their blood out of their body? Even the presidential election was affected by the ‘quackery’. It was a campaign topic that was trumpeted throughout the campaign. With no forensic pathologists to deal with such cases, most autopsies get poorly done by untrained registered medical practitioners or are not done at all, but in the end, conclusions are drawn based on questionable evidence generated and decisions made in court. One cringes when one thinks of the miscarriages of justice possible under such a system. Even with years of experience doing thousands of autopsies, many pathologists recount cases that were so complicated they needed to work as a team ( pathologists, forensic scientists, detectives, Coroners and district attorneys ) to make any head way. With no such team in Ghana, you can imagine what the results are for such cases. Many murders are not solved, and suspects are released because of lack of evidence.  On occasion an innocent person may be convicted for a crime he did not commit.

 

To make matters worse, the Coroner’s Act of 1960 stipulates that those who carry out such autopsies should be paid a now agreed sum of 5 Ghana cedis per case, and oh! that is not a typo it is correct, less than a dollar per case and this is 2019 price for an (1) autopsy done. Now, it even gets worse because I don’t remember the last time this money was paid (maybe 2010). This is despite the fact that for some cases the pathologist or registered medical practitioner has to go to court at least twice to testify and that may require him driving from Accra to Cape Coast or wherever the case is being adjudicated. Then the long wait in some courts, sometimes for the entire day makes one sweat just thinking of the work waiting behind while you sit listening to aristocrats with peculiar dresses ‘acting’ in a room where the one who shot the one you autopsied sits right behind you or next to you and keeps making cat calls at you just before you mount the witness stand.  For many autopsy physicians going to court in connection with an autopsied decedent is such an ordeal that many decline to honor subpoenas even with the prospect of being in contempt of court. The downside of this is that families have to step in if they want an autopsy done. Many pathologists and registered medical practitioners will only do an autopsy outside of their hospital if the deceased’s family agree to pay for their transportation and time. Short of that, family members must bear the cost of transporting the relations body to the nearest autopsy center which may be as far as Tamale if one is in the Upper East region. A dedicated forensic service will transport experts to the site of a crime and carry out investigations at no additional cost to relations because all the experts will be paid to do that.

 

The Coroners have their own problems as well. Many Coroners I dare say have little understanding of how a Coronial system or medical examiners office should be run because there has never been one. They probably have no orientation about their pivotal role in investigating unnatural deaths or deaths in the community. As an example, even though inquiries are crucial in any Coronial system, I have not attended one in my entire period of practice as a pathologist, despite performing well over 3000 autopsies. I only recently read online that one will be held because a very rich Nigerian died and all the big people in Ghana are interested. They may have promised the family that you know. As a teacher, my university and hospital duties leave me with little time to spare and I have on occasion thought about not doing any of such forensic cases since I am not obliged to. The problem is the police commander and the CEO of my hospital get called by the politician and then CEO calls me and then it goes on and on. Anyway, it is even more disturbing if a Coroner makes it difficult for the autopsy physician doubling as a forensic pathologist to carry out his additional pro bono but forced duties. Forced because though one was not employed by either the judicial or police service, the mere fact that you are employed as  a doctor in a Government hospital means you can be ordered by the Coroner to carry out a free autopsy and further write a full report and then top it up with appearing in court, all for free.  If you think the Coroner is your ally then think again, because of a lack of understanding of the Coroner’s Act, the Coroner may well become the biggest stumbling block. Many Coroners and so-called experts have very poor understanding of this curial document which is freely available on the internet. Over the years, time and again I have had to write to a Coroner explaining why a person who is poisoned but ends up in the hospital and dies after 2weeks from the attempted poisoning should have a Coroner’s autopsy. Then again, I have had to explain why I should be given a Coroner’s inquest form for a case erroneously brought to the hospital autopsy suite in my hospital as a clinical / academic case. In both instances the police service and the Judicial service for some strange reason believe that pathologists are just interested in carrying out a Coroner’s autopsy though a patient has been on admission for some time. The current use of one venue for both clinical autopsies and forensic autopsies creates confusion in the minds of Coroners and the police. A dedicated place will reduce if not eliminate this confusion. Then again the state of decomposition of some bodies that require forensic investigation is so advanced that insects that come with such bodies found in bushes, rivers and in locked rooms after days, months or years cross infest bodies of patients who die in the hospital. Imagine patient’s relations walking into a hospital autopsy suite only to find bones recovered from a crime scene or an extensively decomposing shark bitten body of a decedent who was washed ashore. Then again, over time these bodies pile up and are buried in mass burials with many such bodies remaining unidentified. Imagine being killed in a remote part of this country and ending up in the local government hospital as an unknown found dead in the bush, your  end in our current situation is an announcement that someone is missing and a mass burial after a dedicated period of waiting. If your usual habit is to leave home for months on end, you surely will be buried without identification. The autopsy will likely conclude that the cause of death was not ascertained because of advanced decomposition. The current team that is expected to work on such cases lacks the cohesion, skills motivation and place to perform optimally. The lack of understanding of the Coroner’s Act by many Coroner’s and police officers and other professionals who work with it makes it hell to work in the existing chaotic so called Coronial system. It must surely be a requirement that before one is thrown into this chaotic nonexistent system one must be taught how to navigate all the difficulties. A good understanding of the current Coroner’s Act by Coroners will ease the pressure on the system a little.

The police service has its fair share of problems. Detectives are poorly trained and unprepared, and some should never have become detectives. I have had encounters where detectives have begged not to be invited into the autopsy room because they can’t stand the site. Some are morbidly afraid of dead bodies and the autopsy suite and I have seen one drinking some shots of local gin right in front of the autopsy suite before entering. Some come in drunk already and some do not have a clue how to follow a lead or the questions to ask when investigating a death. Many do not understand the role of the forensic pathologist or the forensic anthropologist in investigating criminal deaths. They think the autopsy solves the entire crime and nails the suspect. They don’t understand their role in placing suspects at crime scenes or pinning them to a death in time and space. Exhumations are more chaotic, and villagers crowd the crime scene and practically trample /destroy the evidence while the police watch helpless. Then when you find the rare detective who understands these things, they are nowhere to be found when the really important cases like the missing Takoradi girls need to be investigated, instead apparently more senior but less knowledgeable and also less experienced experts who can only talk are assigned the cases to make a mess of them.  A dedicated service would only employ detectives with the requisite skills. The service should have its own public relations officers and supporting staff. It should also not be subject to the sporadic transfers that currently plaque the police service.

 

As if all these are not enough a request for toxicology will result in relations being charged by the Ghana Standards Authority prior to carrying out the toxicological analysis. This means that relations who refuse to pay for the toxicology do not get the toxicology done and thus the report released by the pathologist will be incomplete unless the pathologist refuses to release that report and risk being sent to the media house as being recalcitrant. If one gets poisoned by close relations in Ghana and these same relations refuse to pay for toxicology, then in our current state, there shall be no toxicology. Again, relations may choose to embalm the body and then pay for the toxicology to be done knowing very well that the report from the Ghana Standards Authority will conclude that poisons could not be detected because the embalming fluid (formalin) screens out the poison. It is scary to note that with the current state of affairs, Ghana is one of the few if not the only country where one of the surest ways to murder someone is to poison the person and get his or her body embalmed summarily. The toxicology may not be done for lack of funds or if done will yield negative results.

 

Finally, at age 62 years, Ghana is a growing nation, never mind that it has delayed developmental milestones. Interestingly, there are many experts in all fields, and these experts apparently know and profess knowledge of their various fields having studied in renowned local and international colleges. Before you think this is a compliment, I dare say that this situation has rather led to an explosion of talkers with very few listeners and even fewer doers. With so many experts shouting at the top of their voices, people only hear their own voices and act on that, a dangerous thing to do considering many of the experts are not exactly practically knowledgeable in what they profess to be experts in. The consequences my friend will say is ‘a lot of talking with little practical results’. I have realized and I’m sure you have too, that that little gets done after all the reports and TV interviews and this has even become a favorite complain for many of us. Enough of being a Ghanaian, we need a dedicated forensic service.

 

KAFUI AKAKPO (PATHOLOGIST SCHOOL OF MEDICAL SCIENCES- UCC / CAPE COAST TEACHING HOSPITAL)