Xxxxxx Xxxxxx Xxxxxx
I am a duly qualified and registered Medical Practitioner and Senior Lecturer in the Department of Obstetrics and Gynaecology (Perinatal Pathologist) and employed by the University of Xxxxx Medical School.

The body was received to the mortuary wearing cotton pyjamas, soaks and with an accompanying pillow. The half of one surface of the pillow was stained dark red/brown colour from apparent vomitus - the colour suggested haematemesis. There were boxer shorts underneath the pyjamas. There was obvious rigor mortis with flexion at the knees, elbows and hips. A moderate amount of brown faecal material was seen in the clothing and smeared about the thighs. It was not abnormally malodorous and not very watery suggesting the child had not had diarrhoea. There was a film of brown material over the chin, the lower lip and the neck and this had also stained the anterior surface of the pyjama top. There was froth at the mouth and when the body was tipped the froth, that was pink and watery ran from the mouth. Three chest lead pads were attached to the upper chest and to the left lateral wall indicating attempts at resuscitation.

FINAL DIAGNOSIS:

STAPHLOOCOCCAL BRONCHOPNEUMONIA PNEUMONIA
and
NECROTISING TRACHEOBRONCHITIS (STAPHYLOCOCCUS AUREUS)

INFLUENZA B/HONG KONG/330/2001-LIKE STRAIN
isolated from TRACHEAL RING

COMMENT TO THE CORONER;
Xxxxxx was a previously healthy child. Three nights before xx died he complained of a headache. The following morning xx had a sore throat but went to school. The next day xx developed wheezy breathing and was given an inhaler as xx had had asthma in the past. The difficulty with breathing continued throughout the evening and appeared to be getting worse. The following morning xx was found in xx bed having vomited blood stained fluid and was lifeless.

Postmortem examination showed that Xxxxxx had haemorrhagic broncho-pneumonia associated with severe necrotizing tracheobronchitis. Staphylococcus aureus was isolated from the lungs and this infection was likely to have occurred in association with influenza B viral infection.

EXTERNAL EXAMINATION
The body was that of a lean normally developed XX year old who was pre-adolescent. The eyes were normal. There were no haemorrhages or petechiae on the sclerae or on the conjunctivae. There was watery red fluid issuing from the left nostril and from the mouth as well as foam. The dentition was normal for the age. The mouth was filled with foamy fluid that was easily expressed on pressure. The ears were normal with no obvious exudate or bleeding from the external ears. There was lividity over the left side of the neck to include the ear. No bleeding site was apparent in the mouth and the tongue was normal. The frenulum was intact and normal.

The trunk was normal. The abdomen was normal and soft. The limbs were normal. There were the usual scars and small bruises over the shins and knees anteriorly related to normal play. No evidence of fresh injury was seen. There were no petechiae or ecchymoses over the skin. There was no subcutaneous oedema. There was no abnormal pigmentation. No abscesses were seen on the skin. The genitalia were normal. The perineum was normal apart from the discharge of faecal material.

There was lividity over the back with sparing of the pressure areas particularly the creasing of the clothes and over the buttocks lividity extended down the back of the thighs and the back of the calves.
The body weight was 31.5kilograms
The body length was 140 (Crown-Heel)

On Sunday, 5 Xxxxx 200X at 1400 hours, on the instruction of the Xxxxx Coroner, I made a postmortem examination of the body of (Xxxxxx Xxxxxx) aged X years, the body lying in the Xxxxxx Hospital mortuary, in the presence of constable Xxxxxx Xxxxxx, Police photographer, Detective Xxxxxx Xxxxxx, Xxxxxx Police, and Xxxxxx (mortuary technician).

Body Cavities
The pleural cavities contained a slight excess of serous fluid. There were no adhesions and no evidence of haemorrhage. The pericardial cavity contained a slight excess of clear serous fluid. The peritoneal cavity was normal. No evidence of perforation of a viscus was seen. There was no evidence of haemorrhage into the mesentery and no adhesions were identified.

Cardiovascular System
The heart and great vessels were anatomically normal. The foramen ovale was still probe patent but otherwise normal. The valves were normal. The myocardium and endocardium were normal with normal firm consistency - no evidence of necrosis was seen macroscopically. The cardiac chambers were normal with no hypertrophy or dilation. The pulmonary venous drainage was normal. The coronary ostia and arteries were normal.

Respiratory System
The larynx, trachea and main bronchi were anatomically normal. The epiglottis was normal with no evidence of swelling. The trachea and bronchial mucosa was deeply haemorrhagic and were coated in a necrotic slough that was grey - particularly towards the carina. There was no evidence of fresh haemorrhage in the bronchi and no excessive mucous.

The lungs showed normal lobation. They weighed 400g combined. The left upper lobe was purple and showed evidence of collapse with focal areas of inflation. The lower lobe was a salmon colour with focal areas of apparent haemorrhage. The right lobes were well inflated and were lumpy due to palpation. There were haemorrhagic foci visible through the visceral parietal pleura. The cut surface of the lungs showed multiple areas of consolidation that were haemorrhagic - the abnormality was far more extensive than had been appreciated from external examination of the visceral pleura. No pus could be expressed from the cut surface that was flat and neither bulged or retracted. There was no evidence of cavitation and the surface was not very oedematous.

Gastrointestinal Tract
The pharynx, oesophagus, stomach, small and large intestines were anatomically normal. The oesophagus was empty and normal. The stomach was distended with approximately 500mls of watery greenish-black fluid with fine black granules in it. The appearances were of so-called ‘coffee grounds’ indicative of gastric haemorrhage. The mucosa showed a normal rugose pattern with multiple fresh haemorrhagic areas that appeared to be superficial mucosal erosions consistent with stress.

The small bowel contained yellow normal bowel contents.
The large bowel contained normal faecal material and gas.
The liver showed normal situs and size. The parenchyma was slightly pale but not remarkably so. No focal areas of haemorrhage or necrosis were seen.
The gallbladder was normal with normal bile.
The pancreas was normal.

Genitourinary Tract
Both kidneys showed normal situs. The cortex and medulla were normal with no evidence of necrosis or haemorrhage. The pelves were normal. The ureters were normal. The bladder was empty and normal.

Endocrine System
The pituitary, thyroid and adrenals were normal. The adrenals showed focal petechiae on the superior surface but no evidence of adrenal haemorrhage was seen and the cortex appeared normal on cut surface.

Lymphoreticular System
The thymus was normal and weighed 33g with no evidence of haemorrhages.
The spleen weighed 96g and was normal with firm parenchyma. There was no evidence of reactive white pulp macroscopically.
Normal lymph nodes were noted in the small bowel mesentery and about the hilum of the lungs.

Central Nervous System
The scalp and skull were normal and intact. No evidence of injury to scalp or skull was identified. The meninges were deeply congested. The brain was smooth and symmetrically swollen. The inferior surface of the brain showed a symmetrical fullness of the cerebellar tonsils and a linear depression just lateral to the medial aspect of the uncus indicating herniation through the tentorium and although there was no evidence of coning, the cerebellum appeared significantly swollen.

The meninges appeared shiny and normal. Cerebrospinal fluid was withdrawn prior to opening the skull and was clear apart from traumatic bloodstaining.
No evidence of haemorrhage was seen in the subdural or subarachnoid space. There was no discolourtion other than remarkable congestion.
Coronal section of the cerebral hemispheres showed normal grey-white matter differentiation and congested parenchyma. The ventricular system was normal. The corpus callosum was normal. No focal lesions were seen.

Samples Taken
Cerebrospinal fluid - Alpha haemolytic strep and Coagulative negative Strep.
Tracheal ring tissue culture - Influenza B/Hong Kong/330/2001-like strain isolated
Spleen - no growth.
Liver - no growth.

Tracheal ring (Micro) - heavy growth Staph aureus.
Right lower lobe lung - heavy growth Staph aureus.
Left upper lobe lung - heavy growth Staph aureus.
Bile - scanty growth Staph.aureus, scanty growth H.influenzae.

Histological examination of tissue
Trachea: The tracheal mucosa was entirely necrotic and there was a layer of necrotic slough overlying attenuated regenerating epithelium. In the subepithelial stroma there was vascular ectasia and a moderately dense round cell inflammatory infiltrate. Dense colonies of bacteria lined the lumen and were adherent to the necrotic slough.
The appearances were of severe necrotizing tracheitis.

Lungs: All lobes showed the same features. There was a severe bronchitis and bronchopneumonia. The conducting airways showed variable loss of epithelium and the lumina were filled with polymorphonuclear leukocytes. Multiple abscesses were seen in the parenchyma and these were associated with adjacent parenchymal haemorrhage. In the centre of the abscesses were dense colonies of the Gram positive cocci. The appearances were consistent with the microbiological detection of Staph.aureus leading to abscess formation in the lungs. The intervening lung parenchyma appeared normal. There was focal pulmonary haemorrhage.

Brain: Sections from the cerebral hemispheres, cerebellum and brainstem showed no abnormalities. In particular there was no evidence of meningitis or encephalitis and no evidence of vascular thrombosis was seen in the sections examined.

Liver: The liver architecture was normal. The portal tracts were normal apart from very isolated portal tracts showing an increase in lymphocytic population. Occasional focal areas of steatosis were seen but there was no overt evidence of hepatitis. No abscesses were identified in the sections examined.

Kidneys: The kidneys were normal with no evidence of acute tubular necrosis, no haemorrhage and no evidence of vascular thrombosis seen in the sections examined. No evidence of nephritis was identified and there were no abscesses seen.