Coroner's Inquest Research Articles

A Modern Analysis of a Historical Pediatric Disaster: The 1927 Bath School Bombing

Children have unique anatomy and physiology that may necessitate a unique approach to a pediatric surge. An analysis of the Bath school bombings of 1927, the largest pediatric terrorist disaster in U.S. history, provides an opportunity to gain perspective on pediatric patterns of injury and future disaster preparedness. Eighty-nine contemporary newspaper accounts, the official coroner's inquest, interviews, online resources, and the Michigan state archives of the disaster were reviewed with respect to the demographics, pattern of injury, gender, age, duration of hospitalization, relative distance of each classroom from the blast, and severity of injuries sustained using the Injury Severity Scale (ISS). Eighty-seven children and three teachers were unable to safely evacuate the building; 36 children (41%) were dead on-site, 40 sustained mild injuries (76.9%), nine sustained moderate injuries (17.3%), and one sustained serious injuries (1.9%). Mean ISS scores decreased with increasing relative distance of each classroom from the primary blast, while the classrooms involved in structural collapse had the highest initial mortality and ISS score. Patterns of injury sustained imply a predominance of crush and penetrating trauma. Mean ISS scores and initial mortality by classroom were a function of proximity to the blast and structural collapse. The pattern of injury closely approximates those of other pediatric disasters such as Columbine, Oklahoma City, and 911. The absence of severe abdominal trauma and one reported hospital mortality may reflect an initial under-triage of patients, possibly due to the medical technology ofthe times.

Investigation of the Failure of the Newcastle Workers Club

The collapse of the Newcastle Workers Club during the Newcastle Earthquake in late 1989 was the subject of a Coronial Inquest, but no firm conclusions were reached. This paper describes an independent investigation of the reason(s) for the collapse. It outlines the investigation process, the data available for the investigation, eyewitness accounts not previously published, and gives a systematic overview of the progression of the investigation. It is concluded that while ground-shaking caused by the earthquake was the prime cause, failure would have been unlikely if there had not been significant deficiencies in the structure as built. These and the most likely sequence of failure events are described.

Coping with a coroner's inquest: a psychiatrist's guide

SummaryDuring the period 2000–2004 the average annual suicide rate in England and Wales was 10.2 deaths per 100 000 population over 10 years of age. About a quarter of those who take their own lives are in contact with mental health services in the year before their death. This means that an average in-patient, sector or community psychiatrist is likely to experience the death of at least one patient by suicide in most years. Suicides by patients cause considerable distress for the psychiatrist that is unlikely to resolve until after the coroner's hearing. This article discusses suicide prevention and provides guidance for psychiatrists on preparing for a coroner's inquest following a patient's death that may have been by suicide.

Pathology of firearm mortalities in the Niger Delta region of Nigeria: a study of 136 consecutive autopsies

A prospective autopsy study of firearms-related death was carried out by the authors in the Niger Delta region of Nigeria. The purpose of the study was to evaluate the pattern, frequency, and anatomical sites of wounds, also the cause of death and the age and sex distribution of victims. The autopsies were performed after being served with the coroner's inquest forms. In all cases standard autopsy procedures were adopted and reports issued. A total of 136 consecutive firearm deaths were autopsied. There were 122 (89.7%) males and 14 (10.3%) females, giving a male to female ratio of 8.7:1. The highest number of deaths, 95 (69.8%), occurred in the age group of 10-39 years with a peak of 51 (37.5%) deaths at 20-29 years. In 112 (82.4%) cases death occurred from homicidal gunshot wounds. The commonest targets of gunshot wounds were the head, 58 (42.6%); multiple anatomical sites, 30 (22.1%); chest, 16 (11.8%); abdomen, 11 (8.1%) and neck, 10 (7.4%). Haemorrhagic shock was the cause of death in 131 (96.3%) cases. Significant causes of traumatic death in the Niger Delta region of Nigeria are gunshot wounds and associated complications. Stringent laws on illegal firearms handling should be passed and enforced by the government to reduce the frequency of such deaths.

“‘I have done it and I have got to die’: Coroners' inquests of abortion deaths in Rhode Island, 1876–1938.”

This article offers an analysis of abortion deaths among white working-class women in Providence County based on thirty-three coroners records from 1876 to 1938. Most women were single and in their twenties: they chose abortion either because their lover was married, or they were too ashamed of their premarital sexual activity to confront their parents. Married women, on the other hand, did so primarily due to economic factors, extramarital affairs, or a strong desire for no more children. In seeking abortions, single women depended on lovers while married women relied on sisters or sisters-in-law. In investigating the deaths resulting from these abortions, coroners called husbands, but not lovers, before the inquests and sought out antemortem statements. Yet only 39% of cases had dying declarations: either doctors refused to participate in interrogating women on their death beds, or women refused to identify abortionists. Of the abortion providers identified, 45% were physicians. Working-class status did not prevent these women, and later their families, from securing expensive medical care from doctors. Both inquests and newspaper coverage in Providence County differ from studies by other scholars who find these venues used as mechanisms to embarrass women and warn single women of urban threats, and to target midwives over physicians. The evidence points to analogous handling of doctors and laypeople, and of married and single women. No intimate details of women's lives were exposed and newspapers did not use sensationalized headlines to draw attention to the illegal activity of abortion. Coroner inquests asked questions necessary to investigate death from a criminal activity, not to take a moral stance on female sexuality.

'Rogues of the Meaner Sort'? Old Bailey Executions and the Crowd in the Early Nineteenth Century

In February 1807, 30 people were crushed to death in a crowd of some 40,000 spectators attending a public execution outside the Old Bailey. By examining the biographical data recorded in the subsequent coroner's inquest, this article reappraises contemporary depictions of punishment crowds as being composed largely of a feckless and troublesome rabble. What emerges is a more rounded picture of the execution crowd, demonstrating how the events attracted a socially diverse and relatively more 'respectable' audience than is often described. This article also addresses a recent historiography of crime and punishment which has assigned a declining relevance to the spectacles, during a period of civic and moral improvement. It argues that executions retained a universal appeal across all quarters of London in spite of their grisly context, and represented important and enduring public spaces of sociability well into the nineteenth century.

Changing trends in maternal mortality in a developing country.

To have a 5-year review of the maternal mortality ratio in the largest centrally located Mission hospital in Benin City where a large proportion of women deliver yearly. This was a 5-year (January 1, 1996 through December 31, 2000) review of the causes of maternal mortality at the Saint Philomena Catholic Hospital, Benin City. The case notes of those that suffered maternal mortality were retrieved and thoroughly perused. Information on all cases of maternal mortality were extracted from the patients' case-notes; the labour ward Registers; the antenatal, postnatal, the female ward and the theatre registers. The midwifery/nurses' reports were also examined. The duplicate copies of the death certificates were examined and the necessary information was also extracted. The total deliveries for the period were extracted from the delivery registers. There were 7055 women who gave birth during the 5-year period. There were 32 maternal deaths; Maternal Mortality Ratio (MMR) of 454/ 100,000 live births. Unbooked emergencies accounted for 68.7% of all deaths, and were more than doubled the booked women. The MMR increased progressively from 325 in 1996 to peak at 765 in 1999 (P < 0.0001) with an insignificant drop in 1998 (P > 0.06). It was lowest in 2000 (241) (P < 0.0001). Paradoxically, as the number of deliveries decreased progressively from 1530 in 1996 to 1247 in 2000, the MMR increased progressively from 327 in 1996 to 675 in 1999. There were no postmortem examinations and no coroner's inquests. More than 76% of the women spent 48 hours or less from time of admission to death and majority of them were of low parity. Nulliparity was 37.5%. The mean parity was one. Young women 20-39 years old accounted for 81.3% with 9.4% teenage deaths due to illegally induced abortions. Eclampsia (34.4%), hemorrhage (25.0%), Infections (18.8%) and abortions 12.5%) were the four leading causes of death. Puerperal deaths were 56.3%. Five short case scenarios were presented to highlight the tortuous pathway the women passed to end in maternal mortality. The MMR ratio was still unacceptably high. The causative factors were largely preventable. The puerperium was the most dangerous period. Women empowerment, free or highly subsidized universal antenatal care services, and provision of adequate emergency obstetric services with effective contraceptive backup is suggested. Re-orientation of care givers and community leaders to enhance awareness and early recognition of the danger signs and risk factors associated with pre-eclampsia and eclampsia with prompt and adequate management or referral is emphasized.

Turing: a bit off the beaten path

M athematician, logician, World War II codebreaker , father of modern computer science, one of Tlme magazine 's Top 20 scientists and thinkers of the twentieth century. Most readers of the IHtelligencerwill probably already have at least some degree of familiarity with Alan Turing and his life story. Turing died in 1954, just a few weeks shy of his 42nd birthday, of what a coroner 's inquest concluded was a self-administered dose of potassium cyanide. Andrew Hodges explores the frustratingly ambiguous circumstances surrounding Turing's death in his excellent 1983 b iography of Turing ([HI: see also [Hi, p. 25]). (A partly eaten apple found on the table beside Turing's bed has general ly been assumed to have had something to do with matters.) The Postscript on page 529 of Hodges ' s book concludes with a rather forlorn-sounding, "There is no memorial." A couple of years ago, [ was pleasantly surprised to learn that this last assertion is no longer correct. Since June 2001, a poignant, life-like, life-size sculpture of Turing has resided in a small public park in central Manchester, Engkmd, located just a few minutes' walk flom the University of Manchester's Sackville Street campus. If my survey of about twenty colleagues and collaborators provides any indication, this remarkable grass-roots memorial to Turing could benefit from a bit more publicity within the mathematical community. Strangely enough, i myself only learned of the sculpture when, in a Minneapolis coffee shop, I happened to pick up a copy of one of our smallest alternative newspapers and wits startled to encounter a picture of it prominent ly featured in one of the articles. (I seem to have somehow missed any news of the thing in the "more standard" media 1 norreally scan.) In June 2004, I had the oppor tuni ty to make a short mathematical visit to Manchester as part of my three-week stay at the Isaac Newton Institute in Cambridge (and their "travelling lecturer" program). I had never been to Manchester before and thought it wou ld be interesting to give a lecture there and to take at least a brief look around. (It was in looking around, in fact, that the idea of possibly preparing a tourist section essay along the present lines first hit me.) The program at the Newton Institute that I was participating in had as its focus recent connections between random matrix theory and zeta functions. Perspective-wise, I think it's fair to say that people come to Turing along a variety of avenues, some more common than others. With me, the desire to "pay Mr. Turing a visit"

The size of lumbar vertebral endplate areas—Prediction by anthropometric characteristics and significance for fatigue failure due to whole-body vibration

The sizes of vertebral endplates co-determine the ultimate strength of spinal units. The health risk associated with fatigue failure after repetitive dynamic loads caused, e.g., by whole-body vibration (WBV), could depend on the size of endplate area, too. An easy low-cost prediction of the latter would be of practical interest. CT-scans of lumbar spinal units of 53 male donors (33.2±5.8 yr) were used to determine accurately the size of the cross-sectional areas of endplates L3–L5. Anthropometric measurements were obtained during coroner's inquest. The correlations between these measurements and the endplate areas were examined. The results do not permit a prediction of the endplate area by anthropometric parameters. This contradicts earlier findings that describe close correlations between the size of intervertebral discs and the size of the endplates and external diameters of large joints. Thirty of 53 spinal units were selected and loaded with static and dynamic compression (5 Hz, 100,000 cycles). The results of these experiments are compared with a method to predict fatigue failure by the predictors size of endplate area, bone mineral density, static and peak-to-peak dynamic loads. Relevance to industry External anthropometric characteristics cannot be used to predict the size of lumbar vertebral endplates which are relevant to the individual tolerance towards WBV. The results suggest a critical interpretation of current guidelines for the evaluation of WBV and other workloads linked with repetitive strain of the lumbar spine. Large normal ranges of spinal compression strength emphasize the importance of individual characteristics for health risk assessment and occupational health care.

Medicolegal autopsies in North Central Nigeria

To determine the pattern and the causes of deaths reported to the coroner for medicolegal autopsies in North Central Nigeria. A descriptive retrospective study. Jos University Teaching Hospital, Jos, Nigeria between January 1996 to December 2003. Autopsies reports of 279 subjects whose causes of death were subjects of litigation. The causes of death in medicolegal autopsies. A total of 279 cases of medicolegal autopsies with identified causes of death were recorded representing 89% of all the autopsy examinations performed within the period. In 7.6% of cases, there was no identifiable cause of death. There were 127 males against 52 females with a male: female ratio of 4.5:1 and their ages ranged between two and 74 years with a mean of 34.7+/-8.2 years. Children aged < 15 years made up 29% of the cases and were distributed as follows: 4% of the children were aged 0-5 years, 9% between six to ten years while 17% were between 11 - 15 years. Accidental deaths made up 51% of the cases, homicides 36% and sudden deaths 13%. Road traffic accidents were responsible for 76% of all accidental deaths. Children were affected in 34% of the accidental deaths and half of them were pedestrians at the time of accident. The male: female ratio of deaths from road traffic accidents was 3:1 with mean age of 24 years. In all the accidental deaths, abdominal injuries were responsible for 47% while 30% died from chest injuries. Of the homicide cases male subjects outnumbered female in a ratio of 16:1 and children were affected in 28% of homicides. Injuries sustained during ethnic and religious crisis were responsible for 48% of the deaths from homicide and 15% of them were children. Armed robbery was responsible for 28% cases while physical assaults were responsible for 20% of homicides. Chest injuries were the causes of death in 54% and abdominal injuries in 36% of homicides. Cardiovascular deaths were responsible for 63% cases of all sudden natural deaths referred for Coroner's inquest during the period. Children made up 11% of all sudden natural deaths. Males outnumbered females in cardiovascular deaths in a ratio of 6:1 and 46% cases of them died of hypertensive heart failure, 32% had cerebrovascular accidents, pulmonary embolism in 13.6% and myocardial infarction in 9%. One case of myocardial infarction died during intercourse. Road traffic accidents, violent communal unrest and armed robbery were responsible for 66% of the medicolegal autopsies in our environment. Public enlightenment, good road maintenance and safe driving culture as well as sustainable security for life and property would reduce the incidence of preventable deaths.

Suicide in recently released prisoners: a population-based cohort study

Several studies have been undertaken on suicide in custody, but few on suicide after the release from prison. We undertook a population-based cohort study to investigate suicide rates in recently released prisoners in England and Wales. We used the database of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness for England and Wales to identify all individuals who died by suicide or who received an open verdict at the coroner's inquest between 2000 and 2002. These records were linked to a Home Office register to identify all such deaths in people within 1 year of release from prison in England and Wales. We compared suicide rates per 100,000 person-years in these released prisoners with rates in the general population by using the indirectly age-standardised mortality ratio. We identified 382 suicides occurring in 244 988 individuals within 1 year of release from prison; a suicide rate of 156 per 100 000 person-years. 79 (21%) suicides occurred within the first 28 days after release. In all age groups, suicide rates were higher in recently released prisoners than in the general population. The overall age-standardised mortality ratio for recently released prisoners was 8.3 (95% CI 7.5-9.3) for men and 35.8 (25.4-50.2) for women. Recently released prisoners are at a much greater risk of suicide than the general population, especially in the first few weeks after release. The risk of suicide in recently released prisoners is approaching that seen in discharged psychiatric patients. A shared responsibility lies with the prison, probation, health, and social services to develop more collaborative practices in providing services for this high-risk group.

Indigenous petrol sniffing: lessons from a coronial inquest

Indigenous petrol sniffing: lessons from a coronial inquest

70 The life and trials of Diamond Jim Beaney, colonial lithotomist Melbourne 1876

Diamond Jim Beaney, (1828–1891), otherwise known as Champagne Jimmy led a controversial and colourful surgical life in Melbourne. He arrived in Melbourne in 1857 and was elected as an honorary surgeon to The Melbourne Hospital in 1860 for 5 years and then re‐elected under controversial circumstances in 1875 until 1890. He was the first in Australia to publish a medical text book and is seen by some as a true colonial pioneer in the area of colo‐rectal as well as children's medicine and welfare, in his adopted land. He was charged with murder on one occasion. He was the subject of a controversial coronial inquest into the death of a patient, subsequent to a trans‐perineal cysto‐lithotomy. His notoriety during his life has changed to benevolent acceptance in death, in that he is remembered at The University of Melbourne for bequeathing an annual award to the principal surgical and pathology scholars, in their final exams ‘The Beaney Prize’.

Twice Slain: Female Sex-Trade Workers and Suicide in British Columbia, 1870-1920

Between 1870 and 1920, the voluntary deaths of 13 British Columbian women, identified by coroners and jurors as prostitutes, provoked a response out of all proportion to their numbers. This essay examines this response, focusing first on the narratives created by witnesses at the coroner's inquest on the body, and then on the interpretations of those who did not literally "know" the dead woman. I argue that the bodies of the dead can be read as a text which invoke multiple interpretations and meanings. Running through all the narratives is a discourse of respectability which shifted attention from an examination of the body and morals of one women to that of society as a whole. Those who knew the women read the death in ways that emphasized their own and the deceased's personal connection to the community in which they lived. Coroners, jurors, and the press inscribed their fears of sexual disorder and racial miscegenation upon the bodies of the dead. Through examining and responding to the deaths, the women and men involved in the inquest process helped create and bolster a particular moral and social identity which utilized the prostitute as a metaphor of social evil. When the body of the prostitute no longer evoked this response, prostitutes' deaths were excluded from the inquest process.

Rigor mortis- ein sicheres Todeszeichen?

In the past years an ongoing controversial debate exists in Germany, regarding quality of the coroner's inquest and declaration of death by physicians. We report the case of a 90-year old female, who was found after an unknown time following a suicide attempt with benzodiazepine. The examination of the patient showed livores (mortis?) on the left forearm and left lower leg. Moreover, rigor (mortis?) of the left arm was apparent which prevented arm flexion and extension. The hypothermic patient with insufficient respiration was intubated and mechanically ventilated. Chest compressions were not performed, because central pulses were (hardly) palpable and a sinus bradycardia 45/min (AV-block 2 degrees and sole premature ventricular complexes) was present. After placement of an intravenous line (17 G, external jugular vein) the hemodynamic situation was stabilized with intermittent boli of epinephrine and with sodium bicarbonate. With improved circulation livores and rigor disappeared. In the present case a minimal central circulation was noted, which could be stabilized, despite the presence of certain signs of death ( livores and rigor mortis). Considering the finding of an abrogated peripheral perfusion (livores), we postulate a centripetal collapse of glycogen and ATP supply in the patients left arm (rigor), which was restored after resuscitation and reperfusion. Thus, it appears that livores and rigor are not sensitive enough to exclude a vita minima, in particular in hypothermic patients with intoxications. Consequently a careful ABC-check should be performed even in the presence of apparently certain signs of death, to avoid underdiagnosing a vita minima. Additional ECG- monitoring is required to reduce the rate of false positive declarations of death. To what extent basic life support by paramedics should commence when rigor and livores are present until physician DNR order, deserves further discussion.

Giving evidence at the coroner's inquest

As a pathologist undertaking coroners' postmortem examinations, you can expect to be called on to give evidence at inquests on many occasions. For other medical professionals this is an uncommon and potentially daunting task and this guide …

Elderly Suicide: An analysis of coroner's inquests into two hundred cases in Cheshire 1989 - 2001

Elderly suicide is an index of more widespread disorder and discontent among the elderly, and furthermore is a potentially preventable cause of death. This study used coroner's inquest records of 200 elderly in Cheshire who killed themselves, and in which their unexpected deaths attracted a verdict of suicide. Sociodemographic characteristics, clinical aspects of the suicidal process and health care contact before death are reviewed. Unlike most available studies, cases of unexpected death in which an open verdict was given were not included in this study, which covered a 13 year period. The findings are interpreted and compared to the currently available literature on suicide in the elderly. Late life suicide is characterised by less warning, higher lethality and greater prevalence of depression and physical illness. However, suicide risk often remains undetected. All suicidal behaviour in the elderly should be taken seriously by psychiatric and primary care services, in order to reduce suicide rates in the elderly.

Suicide in New Zealand

This paper explores and questions some of the notions associated with suicide including mental illness. On average, about two-thirds of suicide cases do not come into contact with mental health services, therefore, we have no objective assessment of their mental status or their life events. One method of improving our objective understanding of suicide would be to use data mining techniques in order to build life event histories on all deaths due to suicide. Although such an exercise would require major funding, partial case histories became publicly available from a coroner's inquest on cases of suicide during a period of three months in Christchurch, New Zealand. The case histories were accompanied by a newspaper article reporting comments from some of the families involved. A straightforward contextual analysis of this information suggests that (i) only five cases had contact with mental health services, in two of the cases this was due to a previous suicide attempt and in the other three it was due to drug and alcohol dependency; (ii) mental illness as the cause of suicide is fixed in the public mindset, (iii) this in turn makes psychological autopsy type studies that seek information from families and friends questionable; (iv) proportionally more females attempt, but more men tend to complete suicide; and (v) not only is the mental health-suicide relationship tenuous, but suicide also appears to be a process outcome. It is hoped that this will stimulate debate and the collaboration of international experts regardless of their school of thought.

Difficult Airway Society guidelines

We read with interest the editorial by Chambers (Anaesthesia 2004; 59: 631–3) and the DAS guidelines (Anaesthesia 2004; 59: 675–94). Having recently attended a Coroner's Inquest focusing on the difficulties we had with the airway of a patient in our ICU, we feel that some of the assertions in the editorial cannot go unchallenged. Chambers appears overly pessimistic in his assessment of the status of the Guidelines, with regard to legal precedent. In Branthwaite & Beresford [1] it is stated that: “(Protocols and guidelines) …are best considered indicative of an accepted course of practice rather than the final arbiter of professional standards. However if legal action is brought because harm results from transgression of guidelines or protocols ‘without good reason’ the claimant is very likely to succeed.” This is no different to the position with any prescribed drug or treatment regimen, and we feel that anaesthetists should not fret at the publication of the guidelines. The guidelines themselves are an excellent summary of the knowledge and skills expected of a competent solo anaesthetist, and should be viewed in this respect. The inclusion of cricothyroidotomy is absolutely correct – claiming expertise in airway management without this skill is to court trouble. With the rising incidence of obesity [2], the incidence of airway problems will increase, and cricothyroidotomy is a relatively easy technique to learn, practise and teach. The Life Support courses include this skill, using sheep larynx or manikins for practice. There is therefore no excuse for not having been exposed to it. The wider use of succinylcholine by practitioners not highly skilled in airway management is also likely to lead to problems. The idea of giving a muscle relaxant, regardless of level of airway training, to facilitate intubation is a recipe for disaster. One of the reasons we had to resort to cricothyroidotomy was an abreaction to succinylcholine, causing a ‘can’t intubate, can't ventilate' situation in our patient. We congratulate the authors of the guidelines, but do not envy them the task they have set themselves in keeping them current. In our mind there is no question about whether or not they should have been published, and that the inclusion of cricothyroidotomy as a core skill is to be strongly supported.

The coroner's court and the psychiatrist

In psychiatry we are perhaps fortunate that the death of our patients is not such a regular occurrence as for our colleagues in other specialties or in primary care. However, when death does occur it is more likely to result from some unnatural cause such as suicide. Consequently, the prospect of being involved in a coroner's inquest is a very real and anxiety-provoking possibility for many psychiatrists. This article considers the role of the coroner in England and Wales and the process of investigation of sudden and unexplained deaths, and offers some practical advice regarding such proceedings. It illustrates a number of issues that have been highlighted in coroners' verdicts and have implications for the process of clinical governance. It also considers possible changes to the coroner system that have been proposed recently in several high-profile reports.