Research Article

Failure to Autopsy: The Otto Warmbier Case

Steven A Koehler* and Victor W Weedn

Published: 12/27/2017 | Volume 1 - Issue 2 | Pages: 098-105


Coroner and medical examiner offices are charged with the medicolegal investigation of deaths to determine the cause and manner of death. We describe the recent high-profile case of Otto Warmbier, who tragically died shortly after his return in a coma from North Korea and in which the coroner failed to conduct a complete autopsy, and failed to satisfy the needs of the local, national, and international communities.

Medico legal death investigation offices, including both medical examiner and coroner offices, have a legal responsibility and duty to investigate deaths in the public interest for public safety and public health purposes. Although, they serve the families of the deceased as they can, their raison d’être and priority is service to the greater public good. Thus, they may conduct investigations and even autopsies over the objections of the next-of-kin. Full investigations include a complete forensic autopsy. The utilitarian public interest should, within the constraints of the office resources, drive the decision of whether to autopsy or not. Failure to autopsy can sometimes constitute a breach of faith that the public entrusts in these offices. Empirically, this seems to be a greater problem in coroner jurisdictions than in medical examiner offices. Specifically, we believe the recent case of Otto Warmbier is such a case.

Read Full Article HTML DOI: 10.29328/journal.jfsr.1001012 Cite this Article


  1. Fish IS. Who Killed Otto Warmbier? 2017. Ref.:
  2. Ramzy A. North Korea Says It’s Holding U.S. Student for ‘Hostile Act’. Ref.:
  3. Winsor M. Family of American student who died after release from North Korea objects to autopsy. 2017. Ref.:
  4. Tinker B. What an autopsy may (or may not) have revealed about Otto Warmbier's death. CNN. 2017. Ref.:
  5. Pikle S. Otto Warmbier: The Death Plot. WTD News. 2017.
  6. Full Press Conference with U.S. Student Otto Frederick Warmbier in North Korea, March 1, 2016. YouTube.
  7. Otto Warmbier sentenced to 15 years hard labor in North Korea. YouTube.
  8. Chan M. Otto Warmbier ‘Fought to Stay Alive’ in North Korean Prison, His Father Says. Times.
  9. Syrluga S. Otto Warmbier has extensive loss of brain tissue, no obvious signs of trauma, doctors say. Washington Post. 2017. Ref.:
  10. Hamblin J. What Happened to Otto Warm bier? What we know of the medical case of the young American who was imprisoned in North Korea. The Atlantic.
  11. Roundtree C. What REALLY killed Otto Warmbier? Neurologists reveal the possibilities after the student's mysterious death. 2017. Ref.:
  12. Syrluga S. What happened to Otto Warmbier? When the unthinkable is unknowable. Washington Post. 2017. Ref.:
  13. Miller SG. What Can an Autopsy on Otto Warmbier Reveal?. Live Science. 2017. Ref.:
  14. Wang C. North Korea and the death of Otto Warmbier weigh on US-China relations. CNBC News. 2017. Ref.:
  15. Berlinger J, Sterling J. North Korea: Otto Warmbier's death 'is a mystery to us'. CNN. 2017. Ref.:
  16. Sewell D. Cause of Otto Warmbier's death uncertain; family rejects autopsy. Chicago Tribune/Associated Press. 2017.
  17. Bever L, Cha A. What an autopsy could tell us about Otto Warmbier’s death. Washington Post. 2017. Ref.:
  18. Ohio coroner performs external exam of ex-North Korea prisoner Otto Warmbier before funeral service at school. The Japan Times/AP. 2017. Ref.:
  19. Grinberg E. Family declines autopsy for former North Korea detainee Otto Warmbier. CNN. 2017. Ref.:
  20. McCurry J. How did Otto Warmbier die?. The Guardian. Ref.:
  21. Winsor M. American student who died after release from North Korea mourned at funeral. ABC News. 2017. Ref.:
  22. Otto Warmbier: The Coroner’s Report. NY Times. Ref.:
  23. Shim E. Ex-North Korean captive says Otto Warmbier was likely tortured. UPI. 2017. Ref.:
  24. Pollanen MS. The Dead Detainee: The Autopsy in Cases of Torture. Acad Forensic Pathol. 2017; 7: 340-352. Ref.:
  25. Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Curel, Inhuman or Degrading Treatment or Punishment. Professional Training Series No.8/Rev.1. United Nations New York/Geneva. 2004.
  26. The Minnesota Protocol on the Inestigation of Potentially Unlawful Death. (2016), Office of the United Nations High Commissioner for Human Rights, New York/Geneva. 2017.
  27. Thomsen JL, Helweg-Legsen K, Rasmussen OV. Amnesty International and the Forensic Science. Am J. Forensic Med Patholo.1984; 5: 305-311. Ref.:
  28. Thomsen JL, Vogt J. Forensic medicine and human rights Forensic Sci Int. 1988; 536: 147-151. Ref.:
  29. Thomsen JL. The role of the pathologist in human rights abuse. J Clin Pathol. 2000; 53; 567-572. Ref.:
  30. Saayma G. South Africa: Vulnerable Persons and Groups in a vulnerable Democracy Can Forensic Medical services help to ensure justice in critical time?. Acad Forensic Pathol. 2017; 7: 433-443. Ref.:
  31. Herzog R, Elgort DR, Flanders AE, Moley PJ. Variablity in Diagnostic Error Rates of 10 MRI Centers Performing lumbar spine MRI Examinations on the same patient within a 3-week period. Spine J. 2017; 17: 554-561. Ref.:
  32. Molina DK, Nichols JJ, Dimaio JJ. The sensitivity of computed tomography (CT) scans in detecting trauma: Are CT scans reliable enough for courtroom testimony. J Trauma. 2007; 63: 625-629. Ref.:
  33. Roberts ISD, Benamore RE, Benbow EW, Lee SH, Harris JN, et al. Post-mortem Imaging As An Alternative To Autopsy In The Diagnosis Of Adult Deaths: A Validation Study. Lancet. 2012; 379: 136-142. Ref.:
  34. Jalalzadeh H, Giannakopoulos GF, Berger FH, Fronczek J, van de Goot FRW, et al. Post-mortem Imaging Compared with Autopsy in Trauma Victims-A Systemic Review, For Sci Int. 2015; 257: 29-48. Ref.:
  35. Underwood J. Post-mortem Imaging and Autopsy: Rivals or Allies? Lancet. 2012; 379: 100-102. Ref.:
  36. Brown HG. Lay Perceptions of Autopsy. Archiv Pathol Lab Med. 1984; 108: 446-448. Ref.:
  37. Hirsch CS. Talking to the Family after an Autopsy. Archiv Pathol Lab Med. 1984; 108: 513-514. Ref.:
  38. McPhee SJ, Bottles K, Lo B, Saika G, Crommie D. To Reddem Them from Death: Reactions of Family Members to Autopsy. Am J Med. 1986; 80: 665-671. Ref.:
  39. Sinard JH. Factors Affecting Autopsy Rates, Autopsy Request Rates, and Autopsy Findings at a Large Academic Medical Center. Exp Molec Pathol. 2001; 70: 333-343. Ref.:
  40. Rosenbaum GE, Burns J, Johnson J, Mitchell C, Robinson M, et al. Autopsy consent practice at US Teaching Hospitals: Results of a National Survey. Archiv Intern Med. 2000; 160: 374-380. Ref.:
  41. Jentzen JM. Death Investigation in America. Cambridge, MA, Harvard University Press. 2002; 106-109.
  42. Nelson DF. Chappaquiddick Tragedy: Kennedy’s Second Passenger Revealed.
  43. Damore. L. Gretna, LA, Pelican Publishing. 2016.
  44. Jentzen JM. Op. cit. 2002; 154-155.
  45. Ventura J. The Murder of Antonin Scalia. Amazon Digital Services. 2016.
  46. Moravec ER, Horwitz S, Markon J. The death of Antonin Scalia: Chaos, confusion and Conflicting Reports. Washington Post. 2017. Ref.:
  47. Hamilton County Democrats name new coroner. [Fox19]. 2012. Ref.:
  48. Lakshmi Sammarco Elected Coroner in Hamilton County, Ohio. IndiaWest. Ref.: