Non-medical practitioners may only be familiar with this kind of work through TV or movies. In this Sunday interview, RTL takes a deep dive into the work of a true forensic pathologist.
The autopsy room is a spacious area located on the ground floor of the LNS (Laboratoire National de Santé). On average, two to three autopsies are performed there each week. At the centre of the room are two stainless steel dissection tables. Opposite these tables is a large window overlooking an enclosed courtyard. Along the sides of the room are workbenches with integrated sinks, cabinets, and shelves containing an array of instruments, all made of stainless steel. These include scissors, knives, tweezers of various sizes and shapes, and even a hammer—these are the tools of Thorsten Schwark's trade.
Forensic pathology is something Schwark enjoys. He does not find it distressing to deal with corpses and to determine the causes of their deaths in his daily work.
"It's quite an exciting job. You work with deceased individuals and have to reconstruct what has happened. It's very precise and sometimes fiddly work," says the German doctor, who has been working at the National Laboratory in Dudelange since 2017. "You no longer see the deceased person as a corpse; you start noticing the findings. It's very exciting to be able to draw conclusions from what you see."
However, 60 to 70% of his time is spent behind his desk as the department supervisor. From time to time, he also has to present his findings in court. Schwark doesn't mind these court appearances: "You need to be well prepared. You have to be able to argue. You must be able to talk and not let yourself be cornered."
Rarely on the crime scene
Four forensic pathologists work in the Department of Forensic Medicine at the Laboratory. One member of the team is on call 24/7 in case they are summoned to a crime scene by the court, which rarely happens. According to Schwark, this occurs about once every one to two months, usually when the circumstances of a death are unclear, or the time of death needs to be estimated.
In most cases, the body is brought to the National Laboratory, where the autopsy is usually performed in the days following the death. Three people are involved in the process: two forensic pathologists, one of whom takes the lead, and a laboratory assistant. An autopsy typically lasts between two and four hours, depending on the condition of the body. Schwark recalls his longest autopsy, which took over eight hours and involved a person who had received 66 stab wounds.
Sometimes, the medical examiners are called to the scene where the individual passed away.
"For example, we then carry out a bloodstain pattern analysis. This can be useful if there are still unanswered questions about the offence or how it was carried out."
Not enough autopsies in Luxembourg
Autopsies at the National Laboratory are exclusively conducted by court order. Last year, there were 141 autopsies out of 4,431 deaths, resulting in an autopsy rate of 3.1% in Luxembourg. This rate is higher than it was a few years ago but is still too low, according to the head of forensics, who notes with a smile that every forensic pathologist would argue for more autopsies. However, compared to the European average, which ranges from 2% to 5% of all deaths, Luxembourg still has room for improvement.
Why aren’t more autopsies conducted in the Grand Duchy? Schwark cites two main reasons. Firstly, the death certificate itself is a factor. The Luxembourgish death certificate is too complicated, resulting in many certificates being incorrectly filled out by attending doctors. Consequently, the question of an autopsy often does not even arise.
Secondly, many doctors do not always know what to look for in corpses. Although this is taught during training, for many doctors, that was a long time ago, and most are not frequently confronted with corpses.
In the past, forensic pathologists from the LNS have conducted training sessions with emergency doctors, as they are typically the first responders at a scene. Schwark also teaches courses on determining the cause of death and death classification in the curriculum for general practitioners at the University of Luxembourg. However, no follow up training sessions have been organised for the already established general practitioners. There is still a need for action in this area, but it would require a significant investment of time and a lot of staff.
Forensic pathologists advocate for second autopsy before cremation to become routine procedure
Schwark emphasises the importance of pinpointing precise causes of death, citing a German study from the University of Münster in the 1990s, which revealed that every second cause of death remains undetected. In Luxembourg, out of the 141 autopsies conducted at the LNS, 7 were determined to be cases of murder or manslaughter.
From a forensic standpoint, cremation presents a significant challenge in this regard. Unlike burial, cremation precludes exhumation and autopsy. Therefore, forensic pathologists have long advocated for a secondary "post-mortem examination" by a specialist before a deceased individual is cremated. Schwark believes there is political willingness for this, but the Ministries of Justice and Health prioritize other matters.
"Corpses are not a priority," Schwark remarks.
He also advocates for more frequent autopsies in cases of suicides. This is not only to confirm the nature of the death but also to potentially provide closure for grieving families. In the immediate aftermath of a loved one's death, families may feel overwhelmed and may not see the necessity of an autopsy. However, they might end up regretting this decision later on.
Sudden deaths of young people are always suspicious
Schwark notes that sudden deaths in young individuals are always viewed with suspicion. However, what qualifies as "young" varies and is typically assessed by the medical examiner based on various factors such as the individual's age.
He also stresses the need for more autopsies in cases of sudden infant death. Currently, autopsies in such cases are only conducted when the initial examination raises doubts. However, since the diagnosis of sudden infant death can only be confirmed through autopsy and further investigations, Schwark advocates for a more proactive approach.
"In my experience, we sometimes discover homicides in infants initially suspected of sudden infant death syndrome during autopsy," he shares.
After eliminating other potential causes like shaken baby syndrome, approximately 3-5% of the infant autopsies in his career have uncovered homicides.
"These are not isolated incidents," emphasises the forensic doctor.
According to him, any minor under 18 years of age who experiences a sudden death without any known underlying health conditions should undergo an autopsy.
Unimaginable to work in a hospital
Schwark initially planned to become a surgeon, with a particular interest in vascular surgery.But he entered the world of legal medicine during his doctorate, where he met his wife, and ended up staying. In retrospect, he says it was the right decision.
His work now is considered to be interdisciplinary, as it marries the world of medicine with cooperation with the police, judiciary, social work and even involves working alongside the Ministry of Gender Equality and Diversity, for cases involving domestic violence or hate crime. Schwark says he appreciates the varied nature of his work.
Looking back over a 22-year-career, much of which was spent in Germany, Schwark says he can no longer imagine working in a hospital. Although the majority of medical students begin their studies to heal patients and save lives, this could sometimes be very difficult, the doctor says, particularly when treating patients with serious illnesses, such as young children. He highlights the suffering of the patient and their family, with practitioners often building a relationship during treatment, with no guarantee of the best outcome.
"In medicine you see so many depressing things, that as a forensic medicine practitioner I have to say I'm glad I don't have to go through that. I handle deceased individuals with whom I usually have no personal relationship."
Some cases are hard to shake off
However, Schwark has also encountered some difficult situations in his career. He recalls a particular case from 2007 in which he was called out to a crime scene in northern Germany, in which a mother had murdered her five children aged 3 to 9, and put them in the basement.
"This is gruesome. Sometimes you visit crime scenes which are the most personal environment of the affected individual, and it can be difficult. That sort of thing is hard to shake off."
Another incident which sticks in the pathologist's memory took place in Austria following a fatal traffic accident, after which the victim's parents and sister came in to identify him, and were subsequently devastated. Fortunately, Schwark says his experienced assistant took control of the situation.
"It was too much for me emotionally. I'm not used to dealing with relatives in this sort of context."
A better appreciation of life
Schwark is professionally confronted with death on a daily basis. He says the topic used to be more present in society, particularly because the deceased would usually be kept at home for a mourning period prior to a funeral. In the past, it was normal for death to be a part of life, but these days it is more taboo. "Death shouldn't be pushed aside in society," he says.
This treatment of death has implications in the medical field, such as the topic of organ donation. People need to consider whether they want to become organ donors or not, he says, and that naturally requires them to consider the topic of death.
Schwark says he has achieved a different view of life throughout his daily confrontation with death.
"I think you develop a better appreciation of life if you're more aware of your own transience."
He says other forensic pathologists and emergency doctors have said the same thing, perhaps because they too constantly come into contact with patients dying in their prime, whether this is due to internal or external causes.
"In almost every case we see here, the victim did not expect to die when they did."
