'Two Steps Forward, One Step Back: This is Autopsy Pathology'
"I was summoned by the Arnhem Court and explained a hemorrhage there. I am used to speaking in layman's terms during sessions: a blood effusion under the soft meninges. And then one of the judges said, 'Ms. Kubat, do you mean a subarachnoid hemorrhage?' And I thought, 'Yes!' It was an incredibly satisfying experience to see that the audience really understood what I was explaining."
Since 2015, Prof. Dr. Bela Kubat, MD PhD, served as a professor of forensic pathology at the Maastricht University Medical Center (MUMC), with special focus areas in neuropathology, clinical autopsy pathology, cardiopathology, and postmortem imaging. She supervised medical residents in autopsy procedures and taught forensic and clinical (autopsy) pathology to medical students. She also supervised a PhD candidate. Bela Kubat recently became emeritus professor.
"I grew up with pathology, but it wasn't obvious that I would become a pathologist. Both of my parents were pathologists, but my father didn’t think the job was suitable for me, so I pursued internal medicine, followed by neurology. But there was no work available at that time. When my then-husband got a job in Germany, I ended up in the Neuropathology department at the University of Essen. And I thought, ‘This is my field’. Love at first sight. I never returned to neurology.
A forensic pathologist must be inventive and creative. You receive a body. Something has happened to it. In any case, the person is deceased and you have little to no information. So the question is, 'What could have happened and can I prove that?' You have to be wary of tunnel vision, but otherwise, you have to figure it all out. Keep a clear head and constantly think about assumptions: 'If this is the case, does it make sense? I want to say this now, but why, and can I? How certain am I of my case?' Autopsy pathology is a matter of two steps forward, one step back, thinking, and then two steps forward again.
In 2003, I finished my training and started working as a neuropathologist in Maastricht. Additionally, I was head of autopsies and got the opportunity to join the NFI. But I maintained contact with the clinics in Maastricht and Heerlen because neurosurgery was also performed there. Clinical brain examinations of deceased persons were conducted, and they needed someone for that. So I worked four days a week in The Hague and one day in Heerlen until we succeeded in establishing the first Dutch chair in forensic pathology in Maastricht in 2015."
Has the field changed over the years?
"I believe it has. When I started at the NFI, it was mainly about autopsies. The quality was very good, but we hardly did any additional research. There was also no good laboratory for microscopic tissue examination or material processing. And that analysis can play a role in forensic pathology. Look, if someone is riddled with bullets, you don’t need to examine organs for pathological changes. But suppose you have an elderly person who is robbed and beaten. The attacker leaves, and the victim collapses and dies, while the blows received are not lethal in themselves. Then something else is going on, and you need to be able to investigate that. This aspect has improved. For my two major focus areas, heart pathology and brain pathology, you need a high-quality and specialized laboratory. When I started at the NFI in 2003, we immediately began upgrading the lab to that level so that everything could be done in-house. That also has the advantage that, as a forensic investigator, I know where all the material is. The chain of custody is under my responsibility, and if you transport materials to an external lab, you lose control over it."
You work with other forensic specialities
"That collaboration is important. You can’t do everything yourself. Take postmortem radiology: you need to know how to generate forensic research material. Know how to take X-rays and interpret them. A radiologist has to do that. At some point, in addition to X-rays, we also added a total body CT scan. Opinions within the team varied at the time, but I was an advocate from the beginning. Postmortem radiology and a total body CT scan have real added value. You get information about the skeleton and bones in places that are difficult for us as pathologists to reach. Take the face: we don’t dissect that. But if you have jaw fractures, you can see them very clearly on a CT scan. The same goes for fractures in the arms and legs: previously, you had to completely dissect those. But you can debate whether you really need to do a full autopsy and all kinds of scans in every case. Suppose you have a gunshot wound to the head, do you need to do everything?
For other questions, MRI is undoubtedly the future because it shows the 'soft tissues', such as organs and the brain. A CT scan of the brain in a deceased person is hardly useful. You can still see details on an MRI scan, although it takes longer. A total body CT scan takes 20 minutes. A total body MRI scan currently takes about two to two and a half hours. That’s also a factor. I write my reports commissioned by the Public Prosecution Service, but also and especially for the judge. They have to pronounce a verdict, so they need optimal information. And they read the reports from cover to cover. All lawyers do. As pathologists, we try to attend hearings as little as possible . That’s a kind of quality criterion: it means your report is clear. For body autopsies, I received 2 to 3 summonses per year, about 2 to 3 percent. But there were special cases, such as autopsies on children."
What makes child autopsies different?
"The fact that it involves a child, a defenseless being. Infants: you cannot shake someone to death once they have sufficiently strong neck muscles. An adult or a toddler holds their head steady. Shaken baby syndrome can only happen in infants whose muscles are not yet fully developed. The evidence for this is barely visible to a layperson. You need to do microscopic examination for that. And that is the specialty of the pathologist.
You don’t see shaken baby syndrome. What you see is a thin hemorrhage under the dura mater. You can see that with the naked eye. Beyond that, you see nothing. But with tissue examination of specific areas in the brain, you can use special staining techniques to make damage to the long nerve fibers visible, which, based on their location, point to shaken baby syndrome. Similar findings can be seen in someone who has suffocated, been smothered, or drowned. Then you see the same changes in those nerve fibers, but in different locations. So it’s about the location of the trauma combined with the fact that you don’t find those changes anywhere else. That is almost impossible to demonstrate in court. If I have a torn liver, I can bring a photo and say, ‘Look, this is a torn liver’. But this is so specialized that lawyers or other laypeople won’t benefit from photos.
There have been publications in scientific literature claiming, based on unscientific arguments, that shaken baby syndrome doesn’t exist. And that is, of course, fodder for the defense. They come up with articles, and then you end up in a medical-scientific debate that lawyers can’t follow. Although I do notice that both in the pool of prosecutors and – and this was very nice – in the pool of judges, a kind of subspecialization has developed. As an expert witness, I increasingly noticed that judges were medically knowledgeable when they asked questions. That is, of course, very pleasant.
Doubt is not wrong in itself. But as an expert, you shouldn’t try to be right or solve everything. There are cases of children who may have been shaken. But if I can’t prove it with my research, I have to say that. Even if the Public Prosecution Service might not like it and asks for a second opinion. If I can’t prove it, I accept that. It’s about the truth. And that is never frustrating. A regular doctor can’t cure all people either. Sometimes patients die. You have to learn to live with that."
You are retired. Where should forensic neuropathology head next?
"I would try to get a CT scanner at the NFI so that the scan can be done in-house, and I would closely follow the development of MRI. That technology will sooner than expected allow us to obtain images at the microscopic level. And I think support for more education in forensic medical fields in medical curricula would be beneficial. Emphasizing its importance so that medical students actually learn about the legislation. And not just as an elective course, but as a mandatory part of education, including forensic pathology and forensic medicine. Basic things, so they at least know those areas exist. Because if you don’t know them, you won’t go that way.
In terms of policy, I would want it to be possible to use forensic material for research. Dutch legislation currently prohibits that. While forensic research is also a form of research. In my farewell speech, I talked about injury dating. If you can demonstrate: 'This injury occurred approximately six hours before death, and there was only one person with the victim during that time.' Well, then that person has some explaining to do. That is very relevant, and you can only do that with forensic research. According to the law, you need permission from the next of kin in such cases. But they are usually not present, and you can’t ask them for permission. Years ago, when I was at the ministry, a legal officer said, ‘You can ask the next of kin for permission, can’t you?’ I said, ‘Listen: grandpa is lying dead in bed under suspicious circumstances. The police come, put grandpa in a body bag. No one is allowed near. And then as we walk out, I turn around and say to the next of kin, ‘By the way, can we do some research too?’ How often do you think I’d get permission?’
There is a new law in the making about the use of human material. The NRGD can also keep a finger on the pulse: how is that developing? It would help if the NRGD drew attention to this. In countries like Germany and especially Switzerland, research with forensic material is allowed. The law also has more possibilities for forensic doctors to take material for toxicological blood tests and other matters. This would greatly aid the pursuit of truth."