The role of forensic pathology in the Black Saturday bushfires
The 2009 Black Saturday bushfires in Victoria caused widespread devastation and the greatest loss of life from fire since colonisation, claiming 173 lives. In response, the Victorian Institute of Forensic Medicine (VIFM), in collaboration with the police force and the State Coroner's Office and over 100 colleagues from all over Australia, Indonesia, New Zealand and Japan implemented a disaster victim identification (DVI) process based on Interpol guidelines to identify the deceased persons.[1] A/Prof Richard Bassed is Consultant in Charge of Identification Services at VIFM and explains what was involved.
“In a bushfire scenario, police crime scene officers will go and find the victims. If the bodies are intact then they are usually able to recover the body themselves and take them to a mortuary. In cases where bodies are piled on top of each other and badly burned, then a forensic pathologist, dentist, anthropologist, or someone with similar experience will go up to the scene with the police and help sort out comingled remains. The bodies are then transported to a mortuary where they undergo examination,” said A/Prof Bassed.
CT scanning was conducted on all remains collected from the 2009 bushfires and played a pivotal role in the identification processes, in conjunction with experts in pathology, anthropology, forensic odontology and molecular biology.[2]
“Once the bodies arrive in the mortuary they are photographed, DNA is taken if possible, and they are put into a CT scanner. The radiologist will look at these images and determine the best pathway for an identification. The various teams in the mortuary will then examine the remains to identify the person. Once the reports are gathered and the paperwork is all triple checked, they are sent to the individual specialists who examine the results of the examination again. They will then be compared with the huge number of antemortem records collected from relatives.
“This was the first time in a mass fatality event that CT scanning had been used as a triage method for identification of the deceased. In a DVI situation such as this, it can be used to determine certain indicators such as pacemakers or implants before actually looking at the bodies. Since Black Saturday, CT scanning has subsequently been used to identify the victims of the MH17 crash and the Grenfell tower disaster,” said A/Prof Bassed.
In the Victorian coronial system, the Coroner – a non-medical, legally trained judicial officer – is legislatively required to find the answers to four questions: who the deceased was, the cause of death, how death occurred, and the particulars necessary for the formal registration of the death. The VIFM is an independent statutory authority operating from a purpose-built facility providing medico-legal death investigation services to the Victorian State Coroner.[3]
“There were so many different areas of expertise involved in identifying the victims of the 2009 bushfires because the state of the remains varied widely. We had forensic odontology, forensic pathology, forensic anthropology and DNA specialists all working together. These four groups had to come together with every single case to examine their reports and make sure there was nothing inconsistent in the way that they reported things.”
“Before the findings are presented to State Coroner, all experts involved in the identification process need to be in agreement that certain remains belong to the right person. After Black Saturday, for the first time ever, we held a group pre-meeting to ensure our evidence was consistent before sending to the identification board,” said A/Prof Bassed.
During the operational debrief, new procedures for incorporation into future protocols were proposed, and recommendations made for improvements in their processes which would then be incorporated into preparations for any future mass fatality events. One of the major recommendations following the 2009 bushfires was that, in all scenes where either fragmentation of remains and/or commingling is suspected, recovery procedures are not to commence until consultation with forensic medical/scene specialists has occurred.[4]
“We care deeply about what we do, and we do our absolute best and absolute hardest to reunite remains of victims with families. However, the time required to complete a whole DVI process varies depending on the states of the bodies. In terms of the 2009 bushfires, it took around 3.5 months to identify the 173 victims because they were burnt and fragile.
“Unfortunately, it was apparent from the first day that police, media, and the community at large were of the belief that all deceased must be recovered as quickly as possible. This pressure resulted in commingling of remains due to personnel working in body recovery teams who could not reasonably have been expected to do otherwise in the circumstances, therefore delaying the process. It is therefore important to note that a proper DVI process takes time if you want to get it right, and one of the most important things to us is that we are allowed time,” said A/Prof Bassed.
