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Request For Post-Mortem Report : Step-By-Step

 

Introduction: What Is Post-mortem Report?

Post-mortem report is a document prepared by the registered Forensic Specialist or Medical Officer who served in the Government of Malaysia (Fee Act 1951, Fee (Medical) in 1982) upon completion of a post-mortem performed.

Post-mortem report has two basic components, namely the findings obtained from the post-mortem (such as features or changes produced by an illness, accident, injury, etc.) and interpretation with respect to the causes of death.

All post-mortem reports in accordance with the general format as set out in the Pekeliling dan Garis Panduan Perkhidmatan Patologi Forensik, issued by the Bahagian Perkembangan Perubatan, Kementerian Kesihatan Malaysia in 2002, in which the post-mortem report has informations as in Table 1.

General format of Post-mortem Report

  1. Post-mortem number.
  2. The name, age, nationality, I/C number of the deceased.
  3. Reference number of Borang Permintaan Pemeriksaan Mayat (Polis 61).
  4. Police report number and police station.
  5. Date, time and place of the post-mortem carried out.
  6. The name and I/C number of Specialist / Medical Officer carrying out the post-mortem.
  7. Identification of the deceased.
  8. A brief history of the deceased.
  9. Clothing / jewelery at the deceased.
  10. External examination.
  11. Internal examination.
  12. Specimens taken.
  13. Conclusion.
  14. The opinion (Specialist only).
  15. Causes of death.
  16. Signature, date and stamp of Specialist / Medical Officer.

Table 1: Informations provided in the post-mortem report

The length of time for the preparation of the post-mortem report, Surat Pekeliling Ketua Pengarah Kesihatan Bil. 17/2008 – Garis Panduan Bedah siasat Mayat di Hospital-hospital Kementerian Kesihatan Malaysia issued by the Unit Perkhidmatan Sokongan Klinikal, Bahagian Perkembangan Perubatan, Kementerian Kesihatan Malaysia in 2008 is referred. Post-mortem report shall be prepared by the Specialist / Medical Officer who conducted post-mortem within eight (8) weeks after the completion of the post-mortem performed.

Post-mortem report is very important for the purposes of medicolegal. Just as medical reports, post-mortem report is confidential and only given to next-of-kin and the investigating officer who manages the case only. However, with the permission in writing of the heirs (written consent), post-mortem report can be used by a third party such as an insurance representative and lawyer. Completed Post-mortem report and endorsed by the Specialist / Medical Officer, shall be kept in the Medical Records Department, until it is requested by the beneficiary or other parties.

The Use Of Post-Mortem Report

  • In court

    Post-mortem reports are routinely used as evidence in criminal court proceedings. Usually the post-mortem report will be referred by the public prosecutor to be used in prosecution in court. The information contained in the post-mortem report (like injuries on the deceased and the results of toxicological analysis or alcohol) together with the evidence of the expert witnesses by Specialist / Medical Officer carrying out the post-mortem will be used to strengthen arguments in the prosecution.

    However, based on the Criminal Procedure Code Section 340 (1), if the Medical Officer who made the post-mortem examination of the body of the deceased person is dead or is absent from Malaysia, it shall be lawful to receive any report of that Medical Officer made under the provisions of this Code as evidence with regard to the appearances of the body when examined by that Medical Officer and as regards the cause of death.

  • In investigation

    Post-mortem report usually requested by the police who conducting an investigation on a criminal case, for example, homicides, wounded by gunfire, rape and others. Referring to the Criminal Procedure Code (Act 593), report of the Medical Officer on post-mortem examination (under subsection 331 (2)) shall be admissible as evidence and shall be prima facie evidence of the facts stated in it at any inquiry held under this Chapter XXXII (Investigation of Death). Based on the post-mortem report, the police can get a source of information about the cause of death and injuries on the deceased, and correlation with weapons which can cause death and suspects involved in the case.
     

  • In insurance claim

    Post-mortem report is also required by insurance companies for insurance claims process by the heirs of the deceased. Post-mortem report must eloborate the injury suffered by the deceased and the cause of death of the deceased so as not to contradict the claims made and policies laid down by the insurance company. Details about the causes of death is important because if the death is caused by the unlawful action e.g. suicide, life insurance coverage claims is void and rejected. In addition, if a person driving under the influence of drugs / alcohol died in a road accidents, the insurance claims cannot be made by the heirs of the deceased.

Procedure For Application Of Post-Mortem Report

Application from Next-of-Kin for Husband / Wife / Children / Siblings & Parents

  1. Application in writing or using Form KKM / LP / 1/2008
  2. A copy of the deceased identity document eg identity card / passport
  3. A copy of the applicant’s identity document eg identity card / passport
  4. A copy of marriage certificate (if applicable)
  5. A copy of birth certificate (if applicable)
  6. Statutory Declaration (if applicable)
  7. Copy of burial / death certificates
  8. Payment (according to the type of application)
  9. Related forms (Insurance, EPF, BURUH 90, PERKESO, etc.)
  10. Other documents relating to the treatment of the deceased

Application through Agent / Representative (Insurance, Lawyers, and others)

  1. Application in writing or using Form KKM / LP / 1/2008
  2. Written consent from next-of-kin (to authorize Agent / Representative to obtain reports
  3. Payment (according to the type of application)
  4. Related forms (Insurance, EPF, BURUH 90, PERKESO, etc.)
  5. Copy of burial / death certificates
Table 2: Type of documents required
  • How to request for post-mortem report

    • Post-mortem report request can be made in two ways, namely:
      • By post; or
      • Applying directly to the Medical Records Department in the MOH hospitals using the Form KKM/LP/1/2008 (Appendix 1), which is available at the Medical Records Department.
         
  • Individual who may apply for a post-mortem report

    • Post-mortem report can only be claimed by:
      • The next-of-kin (example: husband / wife / children / siblings / parents).
      • The agent / representative (insurance / lawyer) with a consent letter from the next-of-kin.
      • The Royal Malaysian Police.
      • The court.
  • Forms / documents required for application of post mortem report

    • Documents required during the post-mortem report request are determined by the category of application. Refer to Table 2.
    • The applicant shall include complete information and submit the following documents (as applicable).
    • How to complete Form KKM/LP/1/2008 as per Appendix 2.
    • Letter of Consent: Post-mortem report request by a third party, the following conditions must be complied with, namely:-
      1. The original letter of consent signed by the next-of-kin. Copy of Marriage Certificate / Birth Certificate of the applicant showing the relationship of the patient.
      2. If the patient dies, confirmation of a valid beneficiary in terms of the law must include the relevant documents as proof.
      3. For foreigners who died, or their heirs could not be contacted, it should be accompanied by a letter of consent from the Embassies State concerned.
      4. Exemption Letter of Consent: Application from the agency has been authorized under the provisions of law for the purpose of the investigation such as:
        • The Royal Malaysian Police.
        • The Court
  • Fee / charge for post-mortem report request

    • The fee charged to the applicant to apply for a post-mortem report in the Medical Records Department in the MOH hospitals is equal to payment / charge for application for medical reports, as set out in Fees (Medical) Order 1982 and Fee (Medical) Amendment 2003 – for foreign nationals.
    • The charge / fee for foreigners is twice the charge imposed on citizens.
    • Payment rates vary according to the type of report and form. Refer to Table 3.

Report / Form Type

Total Payment

Citizen

Foreigner

Brief reports / opinion by Medical Officer

MYR 40.00

MYR 80.00

Brief report / opinion by Specialist

MYR 80.00

MYR 160.00

Full report / comprehensive opinion by Specialist – depending on the complexity of the opinion

MYR 200.00 – MYR 1000.00

MYR 400.00 – MYR 2000.00

Reports requested by the Police / court

Free of charge

Free of charge

Report requested by the Department of Government

Free of charge

Free of charge

Each insurance form

MYR 40.00

MYR 80.00

Table 3: The charge / fee for request for post-mortem report

Duration Time For The Preparation Of The Post-Mortem Report

  • Post-mortem report will only be processed once the complete application is submitted in writing together with the required documents.
  • If complete information is not received within two months, the application will be considered void.
  • If the post-mortem report is still needed, the new application process to be made again.
  • The length of time for the preparation of the post-mortem report is calculated from the date of receipt of a completed application until the date of the post-mortem report completed.

The Reasons For The Delays In The Application Process Of Post Mortem Report

  • The incomplete documents from applicant.
  • Delays in application delivery to Specialist / Medical Officer concerned.
  • Delays in the preparation of report by Specialist / Medical Officer (pending the results of laboratory tests)

The Process Of The Preparation Of The Post-Mortem Report (See Appendix 3)

  1. Registration of application for the post-mortem report
    • All applications must be registered and recorded in the Medical Records Department.
    • Check the application whether the information is complete or not.
    • Surat Akuan Penerimaan Permohonan must be issued to the applicant (see Appendix 4).
    • Refer to the Department of Forensic Medicine to get the post-mortem report.
       
  2. Preparation of the post-mortem report by Specialist / Medical Officer
    • Post-mortem report shall be prepared in accordance with the prescribed period refers to the Surat Pekeliling Ketua Pengarah Bil.17/2008 – Garis Panduan Bedah Siasat Mayat di Hospital-hospital Kementerian Kesihatan Malaysia.
    • If the report had been completed, the report will be sent to the Medical Records Department.
    • For complicated cases such as homicides or cases requiring laboratory test results, the report must be completed when a laboratory test results obtained.
       
  3. Submission of the post-mortem report to the applicant
    • Post-mortem report can only be issued through the Medical Records Department.
    • Medical Records Department is responsible for informing by phone or send a Notis Pemberitahuan Laporan Siap to the applicant (refer to Appendix 5) (any communication by telephone shall be documented).
    • Applicant who wish to take the report must bring a Notis Pemberitahuan Laporan Siap / written consent from beneficiary states to authorize agent / representative to get the report.

References

  1. Hanzlick, R. L. (2000). The Autopsy Lexicon: Suggested headings for the autopsy report. Archives of Pathology & Laboratory Medicine, 124 (4), 594-603.
  2. Jane, M. How to Access Coroner Reports. Retrieved from http://www.ehow.com/how_7243941_access-coroner-reports.html
  3. Koponen, M. A. (2012). The Autopsy Report. Retrieved from http://emedicine.medscape.com/article/1718019-overview
  4. Pekeliling dan Garispanduan Perkhidmatan Patologi Forensik 2002
  5. Pekeliling dan Garispanduan Perkhidmatan Perubatan Forensik 2004
  6. Surat Pekeliling Ketua Pengarah Bil.17/2008 – Garispanduan Bedah Siasat Mayat di Hospital-hospital Kementerian Kesihatan Malaysia
  7. Surat Pekeliling Ketua Pengarah Kesihatan Bil 16/2010 – Garispanduan Penyediaan Laporan Perubatan Di Hospital-hospital &  Institusi Perubatan Kementerian Kesihatan Malaysia
  8. Thomas, R. Investigation of Insurance Death Claims. Retrieved from http://www.pimall.com/nais/n.dcrdt.html

 

Last Reviewed : 8 September 2015
Writer : Nur Ayunni bt. Ab Rahman
Accreditor : Saravanakumar a/l Maniam