On the handling of German citizens who died abroad

There is no systematic national procedure for dealing with German citizens who have died abroad after the body has been repatriated to Germany. This can be a problem, especially in cases of unclear or non-natural deaths. In Hamburg, in cooperation with the Port Medical Service (PMS), there has been a systematic verification procedure (Fig. 1) for decedents returned to Hamburg from abroad via the airport or port since 2007.

Due to globalization and increased mobility, the number of German tourists abroad and German emigrants has been continuously increasing since the end of the last century [1‐3]. Due to these developments, people are also increasingly dying outside their home country. A repatriation and burial of the body in the home country is common. For cross-border transport of corpses, an international body passport (see info text) is required, for which a medical death certificate issued by physicians in the country of death is mandatory [4]. A further examination of the body by German physicians is not mandatory as the international body passport is considered a death certificate [5]. This also applies in the case of a non-natural death. The responsible investigating authority is not regularly informed about all deaths abroad; therefore, national totals are missing for valid statistics. According to Riemer et al. [6], since 2007 in addition to the epidemic hygiene clarification a formal and content-related check of the documents accompanying the corpse of all German citizens repatriated via the port or airport of Hamburg has been carried out by the PMS in Hamburg. In the event of illegible documents, discrepancies or a non-natural manner of death, the PMS sends a report to the responsible state criminal investigation office (LKA). The investigating authorities then often request an external postmortem examination by a forensic pathologist and, in some cases, a forensic autopsy. The results of the external and internal autopsies are communicated to the investigating authorities.

A retrospective evaluation of all cases of German citizens who died abroad and were examined at the Institute of Legal Medicine (ILM) in Hamburg between 2007 and 2018 (external examination or autopsy) was performed. Cases were assigned via a keyword search in the ILM electronic database using the following search terms: “tissue fixation”, “embalming”, “airport”, “hotel”, “port”, “vacation”, “body passport”, “foreign country”, “repatriation”, “body transport certificate”, “ship”, “airplane”. The cases known in the ILM were then matched against the PMS reporting lists for that period, and missing cases were added to the search in the ILM electronic database. For all cases, external examination records and autopsy protocols from the ILM were evaluated with respect to the following parameters: year of death, place of death, age of the deceased, time interval between death (abroad) and examination at the ILM (in Germany), autopsies abroad, and autopsies in Hamburg. Where the information was available, the manner of death indicated on the papers accompanying the corpse was compared with the manner of death determined by the examination at the ILM (external examination or autopsy). In the case of an autopsy performed abroad and a second autopsy performed in the ILM, the completeness of the autopsy performed abroad was assessed, and a comparison was made between the cause of death determined abroad and that determined in the ILM. The evaluation was based on the autopsy guidelines of the German Society of Legal Medicine (DGRM) [7] and the Harmonization of Medicolegal Autopsy Rules of the European Council of Legal Medicine (ECLM, e.g., opening of all three body cavities and examination of all organs) [8]. Data were tabulated and descriptively analyzed.

In Germany, as in some other countries, there is no systematic recording of citizens who died abroad by the registration authorities. In the USA, however, all non-natural deaths of U.S. citizens abroad are recorded by the authorities by country and date of death [11, 12]. Hamburg is the only state in Germany that systematically records at least the deceased repatriated to Hamburg by ship and plane through the system for verification of Germans who died abroad, which was introduced in 2007. In contrast, German citizens who died abroad and were repatriated by land are not systematically recorded in any federal state.

The majority of the documents accompanying the corpse examined in the ILM did not contain verifiable information on the manner and/or cause of death. Comparable studies from Hamburg [6], Great Britain [13, 14], and Frankfurt (Germany) [15] already indicated a lack of completeness of the documents. This could be due to incomplete recording of type and cause of death in some countries, as stated in a World Health Organization (WHO) report [16]; however, no corresponding legislative changes have yet been initiated neither nationally nor globally.

Partially incorrect assessment of the manner of death, as demonstrated in at least five cases in the present study, has already been pointed out in previous studies [6, 15]. Overall, in the present study population, 253 of 307 cases examined (82.4%) had an incorrectly, unspecifically or incompletely completed certificate from abroad. Of these 253 cases 74 were from a European country. This calls into question the status of the international body passport as a death certificate. The autopsy rate among Germans who died abroad in the respective country of death was surprisingly high (approx. 56% for all deceased with subsequent forensic medical examination in Hamburg). Whether this rate is so high only among German nationals or also among domestic decedents in the respective country cannot be judged for lack of publicly available data; however, in the cases that were autopsied abroad and in Hamburg, an incomplete autopsy was evident in 84% of the cases, measured at least by German and European standards; in most cases, the organs had not been completely dissected. The presented results are in agreement with previous studies from Wales [13] and Frankfurt (Germany) [15]. On this rationale, it seems reasonable to strive for a second autopsy on German soil at least for non-natural or unexplained deaths from abroad and for deaths with incomplete records. Postmortem computed tomography (PMCT) could also provide initial results on relevant pathologies as well as on the completeness of the autopsy performed abroad, contrary to the current catalogue of indications, and thus serve as a decision-making aid for a (potentially necessary) second autopsy [17].

In 16 cases the examination in Hamburg revealed a cause of death different from that provided from abroad, both in the external postmortem examination and in the autopsy result. It can be assumed that the actual number may have been even higher, since in many cases no valid comparison was possible due to incomplete information from abroad. Furthermore, it can be assumed that the number of wrong causes of death might have been falsely too low due to the low number of autopsies in Hamburg; however, the present results demonstrate the legitimacy of the Hamburg system for dealing with German citizens who died abroad and should be used for policy decisions in other metropolitan regions or states in Germany. The results of other studies [13, 15, 18] also confirmed that the cause of death recorded in the international body passport does not always correspond to the actual cause of death.

Regarding the quality and quantity of autopsies, Germany is certainly not the gold standard worldwide; however, there are general, also internationally recognized standards to which the pathological and forensic medical institutes in Germany adhere. Since autopsies performed abroad in a relevant number of cases do not meet the standards applied in Germany and papers accompanying corpses are often incomplete or incorrectly filled out, the verification procedure introduced in Hamburg in 2007 is also recommended for other federal states and regions with corresponding ports or airports. In addition, a nationwide registration register for deaths abroad would appear to make sense in order to identify deceased persons who are repatriated by land. This also applies to deceased who have already been cremated abroad. Furthermore, the status of the international body passport as a death certificate appears questionable.