The problems begin with the very first question a doctor must ask: was it a natural or unnatural death? “The former category includes deaths resulting from illness or complications after surgery”, explains Woudenberg-van den Broek. “The latter includes deaths due to suicide, euthanasia, medical error or a crime – some external cause.”
The Dutch postmortem system traditionally distinguishes between natural and unnatural deaths. But this distinction isn’t as straightforward as it may seem, says the PhD graduate, who spent eight years researching the subject for her thesis Death in Denial. “Bacteria and viruses also come from outside the body”, she points out, illustrating how much room there is for error.
Death certificates
“Let’s start with the basics. Dutch law requires that a postmortem be conducted when someone dies”, explains Woudenberg-van den Broek. This means that the person’s GP or treating physician must perform an external examination of the body to confirm the death and establish its cause. “Only if the doctor is certain that it was a natural death can they issue a death certificate.”
But this is where things often go wrong. “If someone has died at home, the GP might just stand in the doorway, glance into the room and sign the death certificate without properly checking. But the body could have unexplained injuries, and it may not have been a natural death at all.” And things can get even stranger. “I’ve even witnessed a case where someone was declared dead when they were still alive.”
Another flaw is the lack of independence in the system. “If someone dies in hospital, for example, their treating doctor conducts the postmortem and determines whether the death resulted from a medical error or a complication.” If it’s the former, it’s classified as an unnatural death – something a doctor may be reluctant to admit. “It’s like marking your own work – or, as the Dutch idiom goes, ‘the butcher inspecting his own meat’.”
Forensic medicine
If there is any doubt about whether a person has died of natural causes, a different process is set in motion: a forensic physician, like Woudenberg-van den Broek, takes over. “I might be called to a crime scene if a crime has been committed, or brought in if there are any concerns about a death. Of course, I could still conclude that nothing is amiss and determine it was a natural death”, she explains.
“But if I believe further investigation is needed, I’ll contact the public prosecutor and recommend a judicial autopsy.” At that point, her role ends, and the Netherlands Forensic Institute (NFI) takes over. “Just to be clear, I don’t perform internal autopsies myself; I only carry out external postmortem examinations.”
Woudenberg-van den Broek’s field isn’t as well known in the medical community as you might expect, as forensic medicine isn’t part of the standard medical curriculum in the Netherlands. “Some doctors don’t even know we exist”, she says with exasperation.
This lack of awareness is evident in practice, where it’s all too common for a natural death to be declared without proper investigation. “That’s where the system fails. Only 6.7 per cent of doctors fill in death certificates correctly. They don’t know any better, because it’s not covered in their training. They just follow the example of their mentors, who often don’t know either.”
Violated regulations
In Woudenberg-van den Broek’s view, the Dutch postmortem system needs a complete overhaul, and the terms “natural death” and “unnatural death” should be abandoned altogether. This distinction, she argues, violates Article 2 of the European Convention on Human Rights. “The article states that everyone has the right to life, and the state is obliged to protect that right”, explains Woudenberg-van den Broek. “This includes the duty to investigate whether that right was violated in the case of a death and whether the death could’ve been prevented.” To comply with this obligation, the facts, causes and nature of the death must be properly recorded. “And we’re doing a terrible job of that.”
She points to England as an example of how things could be done differently. “There, the question a doctor must ask is, ‘How did the person come by their death?’ In other words, why did they die?” This is an essential question, she says, because only when you know the answer can you determine the next steps to be taken. If a crime is suspected, for example, a criminal investigation must be launched. “But you can also advocate for wider change in society, which I think is important – looking beyond the case at hand.”
Woudenberg-van den Broek cites a case from England involving a rugby player who died after a blow to the head. “He wanted to keep playing, insisted he was fine, but eventually collapsed and died. Everyone understood what had happened, but after an investigation by a coroner – a judicial official who investigates sudden or suspicious deaths – an important guideline was introduced.” It was recommended that a nurse be present at all rugby matches to assess whether a player can continue after a hit. “It won’t prevent every tragedy, but I think it’s great that positive change came out of the situation.”