Work-related exposure to asbestos and criminal liability: Forensic challenges from a nine-year autopsy experience

Forensic autopsies provide direct evidence of asbestos exposure and can clarify - but not determine - legal causation. We described mortality patterns and pathological findings in a nine-year judicial series from Udine, Italy. We reviewed 167 autopsies conducted between 2016 and 2024 in which prior asbestos exposure was considered. Asbestos bodies in lung tissue were quantified per gram of dry lung using a standardized digestion and counting protocol. Causal attribution followed published consensus criteria and the applicable legal standard. Decedents were predominantly male and of advanced age. Causes of death were primary lung cancer (47.9%), pleural mesothelioma (22.8%), non-pleural mesothelioma (2.4%), laryngeal cancer (0.6%), ovarian cancer (1.2%), fibrotic interstitial lung diseases (4.2%), other malignancies not attributable to asbestos (9%), and other non-asbestos-related causes (12%). Asbestos bodies were detected in 95.2% (median 3,630; range 110 to 1,700,000). A threshold consistent with occupational exposure was exceeded in 68.9%. Legal recognition of causation occurred in 59.9% and was associated with higher tissue burdens (median 4,708 versus 1,100). Bilateral pleural plaques showed higher medians than unilateral plaques (10,340 versus 1,950). Autopsy data confirm frequent, high asbestos burdens and their alignment with diseases classically linked to asbestos, yet tissue counts alone are insufficient for individual causal attribution. The 2014 Helsinki Criteria reveal substantial limitations when applied in criminal proceedings, where a high degree of certainty is required. Clear, internationally harmonized criteria and explicit reference to the standard of proof are needed to guide the probative use of forensic pathology in criminal contexts.