The Forensic Tabula Rasa – Agreement on Manner of Death from Injury Patterns to the Extremities Only

PURPOSE: In Sweden, the forensic pathologist must determine the manner of death. Contextual information is often used in these assessments. This study investigates the inter-rater reliability and accuracy of forensic pathologists when determining the manner of death based solely on autopsy findings of sharp force injuries to extremities, excluding contextual data. METHODS: 23 forensic pathologists and forensic pathologists in training assessed injury data from 59 cases, visualized using body maps. Inter-rater agreement was analyzed using Fleiss' kappa. Sensitivity, specificity and the influence of experience and number of injuries were evaluated. RESULTS: Agreement among raters was moderate at best. No experience level outperformed others significantly, though senior specialists had a higher specificity. Sensitivity was higher for suicides (0.656) than homicides (0.535), while specificity was high for both (>0.85). The number of injuries positively influenced agreement and sensitivity. CONCLUSION: Forensic pathologists showed only moderate agreement, with better consistency in suicide cases. Experience level had a significant impact of specificity but limited impact on sensitivity, where the number of injuries was a more significant factor. These findings suggest that while extremity injury patterns can be used to assess the manner of death, their interpretative value is conditional and influenced by contextual information.