Connected to the cloud at time of death: a case report.

Background: Our case report provides the first clinical evaluation of autopsy practices for a patient death that occurs on the cloud. We question how autopsy practices may require adaptation for a death that presents via the 'Internet of Things', examining how existing guidelines capture data related to death which is no longer confined to the patient's body.

Case Presentation: The patient was a British man in his 50s, who came to the attention of the medical team via an alert on the cloud-based platform that monitored his implanted cardioverter defibrillator (ICD). The patient had a background of congenital heart disease, with previous ventricular fibrillation cardiac arrest, for which the ICD had been implanted two years earlier. Retrospective analysis of the cloud data demonstrated a gradually decreasing nocturnal heart rate over the previous three months, falling to a final transmission of 24 beats per minute (bpm). In the patient post-mortem the ICD was treated as medical waste, structural tissue changes precluded the effective evaluation of device hardware, potential issues related to device software were not investigated and the cause of death was assigned to underlying heart failure. The documentation from the attending law enforcement officials did not consider possible digital causes of harm and relevant technology was not collected from the scene of death.

Conclusion: Through this patient case we explore novel challenges associated with digital deaths including; (1) device hardware issues (difficult extraction processes, impact of pathological tissue changes), (2) software and data limitations (impact of negative body temperatures and mortuary radio-imaging on devices, lack of retrospective cloud data analysis), (3) guideline limitations (missing digital components in autopsy instruction and death certification), and (4) changes to clinical management (emotional impact of communicating deaths occurring over the internet to members of family). We consider the implications of our findings for public health services, the security and intelligence community, and patients and their families. In sharing this report we seek to raise awareness of digital medical cases, to draw attention to how the nature of dying is changing through technology, and to motivate the development of digitally appropriate clinical practice.