Autopsies: What You Should Know

Thanks to TV dramas, many people assume autopsies are routine for every death. In reality, they’re performed in only a small percentage of cases — and quite a few deaths that should involve an autopsy are missed. As a hospital system, it is imperative that physicians are trained to refer cases to the Medical Examiner/Coroner’s Office for autopsy. Alternatively, our board-certified forensic pathologists are the non-biased set of eyes that will refer to the proper channels 

A Sharp Decline in Autopsies

In the 1960s, autopsies were conducted in 30–40% of deaths. By the early 2000s, that number had plummeted to around 8%. As of 2020, only 7.4% of deaths receive an autopsy. (citation 1) This drop can be attributed to multiple factors: lack of insurance reimbursement, cultural or religious objections, and the growing workload of hospital staff. (citation 2)

Modern diagnostic tools have also contributed to this decline such as improvements in lab work for detection of illnesses as well as radiology. Improved imaging has enabled physicians to have a look at internal factors contributing to a patient’s health. While technology has improved how we detect illness, it’s also fostered a false sense of certainty around causes of death — leading to fewer autopsies and more assumptions. 

Why This Matters

Today, most death certificates are completed by clinicians without autopsy confirmation. Unfortunately, studies have shown significant discrepancies between clinical assumptions and autopsy findings. (citation 3) These gaps affect hospital quality control, skew public health data, and may result in missed opportunities for prevention.

The Goldman Criteria is a series of classifications for discrepancies in autopsies compared to ante-mortem diagnoses. A Goldman class I discrepancy is a missed major diagnosis in which the principle underlying cause of death was missed with probable adverse impact on survival. A Goldman class II discrepancy is a missed major diagnosis with equivocal impact on survival. Class III and IV discrepancies refer to minor missed diagnoses, either unrelated incidental findings or pre-existing conditions thought not to have contributed directly to the patient’s death. In class V there is a complete agreement between clinical and postmortem diagnoses. (citation 4) 

In a study performed at Jackson Memorial Hospital between 2009 and 2014, cases were reviewed by two pathologists. They found that 33 of 334 cases (9.9%) were identified as a class I discrepancy. Major significant findings that had not been clinically detected (class I and II) were found in 65 cases (19.5%). (citation 2) This demonstrates the need to continue performing autopsies despite the technological and medical advancements.  

So when is an autopsy necessary and when is it not?

The "90-Year Rule"

A common (though informal) practice in forensic pathology is the “90-year rule”: autopsies are rarely performed on individuals over 90. The rationale? At that age, multiple chronic conditions are typically present, making the exact cause of death hard to isolate — and usually presumed to be natural.

But not all deaths, even in the elderly, are straightforward.

Situations Where Autopsies Are Essential

Autopsies are critical in certain cases, regardless of age. Even if a cause of death is documented, further review may be warranted — particularly in cases that could involve injury, neglect, or legal questions. Guidelines vary by jurisdiction, but here are common scenarios:

 External Causes

• Fires or severe burns

• Drug overdoses

• Choking or asphyxiation

• Unsafe sleep environments for infants

 Accidental Exposure or Poisoning

• Foodborne illness

• Anaphylaxis

• Hazardous workplace exposure

 Institutional Deaths

• Inmates in prisons or detention centers

• Residents of state-run psychiatric or long-term care facilities

• Individuals in foster care or under protective services

 Unexpected Hospital Deaths

• Deaths within 24 hours of admission

• Patients with no clear medical history or explanation for death

 Workplace Deaths

If someone dies on the job and the cause isn’t obvious, an autopsy may determine if it was due to occupational exposure, physical exertion, or an undiagnosed condition. These findings can influence compensation claims, employer accountability, and workplace safety standards.

 Autopsies and Insurance

Autopsies can be key in settling life or accidental death insurance claims. When the cause of death is unclear or disputed, insurance companies may delay or deny benefits. A thorough autopsy provides the necessary documentation — helping families find clarity and financial support during a difficult time.

Bottom Line

Autopsies aren’t routine, but they are essential in cases involving:

• Injury or accident

• Unexpected or unclear deaths

• Custody or institutional care

• Potential public health risks

• Insurance or legal questions

When the cause of death is obvious — particularly in the elderly or chronically ill — an autopsy may not be needed. But when there's doubt, families, clinicians, and institutions should advocate for one. Accurate cause-of-death reporting isn't just a formality — it’s a matter of public health, justice, and closure.

Citations: 

1. Hoyert, D. L. (2023). Autopsies in the United States in 2020 (National Vital Statistics Reports, Vol. 72, No. 5). U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-05.pdf

2. Marshall, Hyejong Song, and Clara Milikowski. Comparison of Clinical Diagnoses and Autopsy Findings: Six-Year Retrospective Study.

3. Solomon N, Gascho D, Adolphi NL, Filograna L, Sanchez H, Gill JR, Elifritz J. The evolution of postmortem investigation: a historical perspective on autopsy's decline and imaging's role in its revival. Front Radiol. 2025 Apr 14;5:1565012. doi: 10.3389/fradi.2025.1565012. PMID: 40296874; PMCID: PMC12034628.

4. Perkins GD, McAuley DF, Davies S, Gao F. Discrepancies between clinical and postmortem diagnoses in critically ill patients: an observational study. Crit Care. 2003 Dec;7(6):R129-32. doi: 10.1186/cc2359. Epub 2003 Sep 5. PMID: 14624686; PMCID: PMC374369.