Death Investigation System Research Articles

Housing instability increases for stimulant-involved overdose deaths after linking surveillance data to electronic health records in Kentucky

BackgroundAccording to the U.S. Centers for Disease Control and Prevention, approximately 10.2 % of fatal overdoses in 2022 were among people experiencing homelessness or housing instability. In the United States, the majority of all drug overdoses now involve stimulants. MethodsWe linked stimulant-involved fatal overdose records occurring between 2017 and 2021 from Kentucky’s Drug Overdose Fatality Surveillance System to the electronic health records (EHR) of the state’s largest safety-net hospital network. We used State Unintentional Drug Overdose Reporting System (SUDORS) definitions of homelessness or housing instability to establish baseline estimates before linking decedents to medical records. After linkage, we augmented SUDORS data with structured administrative billing codes, semi-structured address data, and unstructured clinical notes identifying homelessness from the EHR. ResultsThere were 313 individuals with stimulant-involved fatal overdoses linked to at least one medical encounter in the EHR (2017–2021). Thirty-three individuals (10.5 %) were identified as having unstable housing according to SUDORS. After linkage, 130 individuals (41.5 %) had evidence of housing instability. For this period, these 313 individuals represent 8.0 % of stimulant-involved overdoses in KY or 38.5 % of stimulant-involved overdoses from residents of the primary and secondary catchment area of our healthcare network. ConclusionsThe single-site increase in observed housing instability in stimulant-involved fatal overdoses suggests that increased data linkage between state medicolegal death investigation system and EHRs would significantly improve the public health surveillance of overdoses.

Unequal burials: Medicolegal death investigation system variation as a determinant of FEMA's disaster funeral assistance allocation

AbstractFederal Emergency Management Agency (FEMA) disaster funeral assistance is available to cover funeral expenses for the relatives of disaster victims in the United States. However, funds are dependent on death certificate proof of a disaster‐related cause of death. Previous research has shown that the medicolegal death investigation (MDI) system may impact the quality of death certificate data. This research examines the relationship between MDI systems and FEMA disaster funeral assistance distribution. The results of the study indicate that centralized medical examiner systems have higher funeral assistance acceptance rates than other MDI system types. Democratic states and counties with fewer minority residents also have higher acceptance rates. Furthermore, acceptance rates varied significantly by FEMA regional office. These findings suggest that the distribution of funeral assistance may be influenced by administrative and political differences between states.

The role of coroner in natural deaths in the elderly in New South Wales, Australia – can this change for the better?

ABSTRACT In 2015, the combined average life expectancy for males and females in Australia was ranked 6th in the world at 82.5 years. The exact age at which a person can be classified as being elderly will differ amongst countries but is generally between 60–65 years. The increase in life expectancy and increased recognition of the elderly as a vulnerable group will most likely lead to an increased workload in the medico-legal death investigation system.

Use of data from death investigation systems to support community health and prevent premature deaths in Canada.

Use of data from death investigation systems to support community health and prevent premature deaths in Canada.

Improving state medicolegal death investigation: Does system level reform improve public health data concerning drug-related mortality?

In the United States, the governance of unnatural death certification varies greatly by state. Although cross-sectional research has linked mortality data quality with variation in medicolegal death investigation systems across states-especially with regards to drug-related deaths-this relationship has not be sufficiently tested using longitudinal data. This research assesses the impact of system governance reform on the quality of drug mortality data by assessing the impact of transitioning from a coroner system to a medical examiner system on data quality. The research finds no evidence that system-level reform is associated with improved drug-related mortality data quality. These findings suggest that alternative methods should be examined for improving public health data concerning drug-related mortality. These likely include focusing on individual-level characteristics and practices of officials and offices, rather than system-level variables.

Analysis of Forensic Death Statistics From 2013 to 2022 and Autopsy Practices in Türkiye

Autopsy rates are significantly lower that what they should be worldwide. Additionally, autopsy practices vary between countries. To examine the autopsy rates, the distribution and temporal changes of forensic autopsy cases, so as to identify the areas in the death investigation system that require improvement in Türkiye. Cross-sectional study. “Forensic Death Examination Statistics” of the Council of Forensic Medicine (CFM) and “Death Statistics” of the Turkish Statistical Institute were compared and analyzed for the years 2013-2022 in Türkiye. The number of forensic death cases sent to the CFM has increased over time. For all causes of deaths, the autopsy rate is approximately 3.6-4.8%. The cause-specific mortality rates for deaths due to sharp instrument trauma, blunt trauma, occupational accident, undetermined, and poisoning have increased over the years. “The percentage of “undetermined” deaths, which are important to demonstrate negative autopsies, was 14.2% in 2021. Although the autopsy rates have slightly increased in a volatile trend over time in Türkiye, they are still not at the desired level. Thus, it is essential to further raise awareness among all professionals involved in death investigations about the importance of autopsies.

The impacts of governing agency: A comparison of resources in the patchwork of medicolegal death investigation systems

In the United States, medical examiners and coroners (MECs) fill critical roles within our public health and public safety systems. These professionals are primarily charged with determining the cause and manner of death as they investigate deaths and respond to associated scenes and mass fatalities and can also help identify trends in public health crises through medicolegal death investigations. Despite their instrumental role, they are organized in disparate systems with varying governing structures, functions, staffing, caseload, budget, and access to resources. This paper examines data from the 2018 Census of Medical Examiner and Coroners to evaluate MEC operations in the United States. The findings show that MEC offices’ organizational and operational governance structures greatly influence resources, workloads, and access to information and services. Standalone MEC offices were generally better resourced than those affiliated with law enforcement, public health, forensic science, district attorneys, or other agencies.1

The Management of Death in Sri Lanka and Potential Solutions for the Future

Death is an inevitable human occurrence, and ancient humans experienced anxiety and apprehension when faced with unnatural deaths. Prehistoric humans valued funeral proceedings and ceremonial rites due to their belief in life after death and reincarnation. Dead bodies can be disposed of legally or illegally. Legal methods include soil burials, entombment, cremation, or donation to medical institutions. Legal disposal requires certification by a medical practitioner and a death certificate. Illegal disposal involves secret burials, such as being thrown into waterways or burnt. Ancient societies used customs like burying corpses in uninhabited jungles or constructing “Towers of Silence” to prevent scavenging by animals. Sea burials are also practiced in some cases. To register a death, authorized individuals confirm its occurrence, transfer the body to undertakers for final disposition, and relatives register it with the registrar of birth, marriage, and death. Various death investigation methods have been implemented in different parts of the world, generally varying based on the investigating authority’s jurisdiction.The death investigation system of Sri Lanka is based partly on the English coroner’s system. The death investigation procedure in Sri Lanka is described in Sections 369 to 373 of the Code of Criminal Procedure (CCP) of Sri Lanka 1980. However, the current inquest system has several deficiencies. It is high time to adopt a system. Sri Lanka should contemplate transitioning from the inquest system to the medical examiner system, as the medical examiner system is more efficient, and several countries followed this successfully.

Pathology and forensic science: Dignity, respect, and the dead body

AbstractThis perspective considers the forensic examination of deceased bodies via the medico‐legal autopsy. It is argued that the decisions we make about what we do with, and to, deceased bodies and body parts is, and should be, limited by the need to treat bodies with dignity and respect. The treatment of parts of bodies has been explored in bioethics, substantially due to organ retention scandals bringing this to the public and political attention. But these cases—although important—represent extremes. This perspective therefore focuses on routine death investigations and the extent to which scientific method should be limited because of the competing interests in the deceased body and its treatment. It is argued that how we treat bodies/body parts matters because they represent once‐living people with contexts, histories, and relationships. They had, and perhaps still have, value as human persons. As humans, we share complex relationships and have different views and interpretations of what our duties are to each other. Dignity and respect aid by providing baseline standards, and are reflected as such in professional codes and regulations. However, the system is imbued with sufficient discretion that it is impossible to achieve consistency of standards or practice. This means that the treatment of deceased bodies in forensic science will differ substantially depending on both context and the practitioners involved.This article is categorized under: Forensic Medicine > Medicolegal Death Investigation Systems

The effects of the (fentanyl-fueled) drug overdose epidemic on medicolegal death investigation in the United States.

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology.

Need for Improved Timeliness of Reporting on Drug Overdose Fatalities: The HEALing Communities Study.

Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information. The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system. Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate. Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.

Development of prevention strategies against bath-related deaths based on epidemiological surveys of inquest records in Kagoshima Prefecture

Sudden death in the bathroom (bath-related death) occurs more frequently in Japan than in other countries. To clarify the epidemiological characteristics of bath-related deaths, we reviewed inquest records of deaths in Kagoshima Prefecture from 2006 to 2019. We identified 2689 cases of bath-related death. Of these cases, 90% were among people aged ≥ 65 years. The majority occurred in a home bathtub between 16:00 and 20:00. Most deaths (52.0%) occurred in winter (December–February), and there were extremely strong negative correlations with the environmental temperatures (maximum, minimum, and mean) on the day of death. We identified the environmental temperature during cold winter months that bath-related deaths are likely to occur in Kagoshima, although further investigation concerning the effects of other confounding factors is required. Forensic autopsies have only been performed in 29 cases and the cause of death was not diagnosed correctly in the majority of cases. Although autopsies are essential to elucidate the pathogenesis of the deaths, it is difficult to increase the rate of autopsies under the current Japanese death investigation system. Therefore, we suggest that the best way to prevent bath-related death is establishing an “Alert system” based on our results, and to have people refrain from bathing on dangerous days.

The Forensic Tradition in Milan’s Civic Mortality Registers

From the late fourteenth to the seventeenth century, many Italian cities and towns responded to recurrent plague by keeping municipal death registers. Different in content and character from the most celebrated form of early modern mortality records, the London Bills of Mortality, Italian authorities named, rather than counted, persons who died. This municipal practice illustrates the invention of secular death investigation systems in an era of recurring plague. Milan’s uniquely detailed civic death registers, 1452 to 1525, display the underlying forensic character of such record-keeping, rather than the public health context in which such records have long been understood. Diagnosing the cause and manner of death, the fundamental objective of forensic medical inquiries, exposed epistemological uncertainties that academic medicine largely avoided for the entirety of the early modern era. How could one be certain that a death was caused by a particular affliction? Our death investigation practices are now far more sophisticated, but in the current, tenacious SARS-CoV-2 pandemic, we still struggle to measure and record the human costs of crisis mortality.

Do Sheriff-Coroners Underreport Officer-Involved Homicides?

In the United States, each state sets its own standards for its death investigation system. These may require independent medical examiners and coroners or allow for the sheriff to assume the role of coroner. Motivated by the well-established fact that counts of officer-involved homicides in official data sets grossly undercount the number of these incidents, we examine the possibility that different death investigation systems may lead to different death classification outcomes. To examine the potential differences in officer-involved homicide underreporting by presence of sheriff-coroner and violent death type (gunshot, intentional use of force, pursuit, or other vehicle accident), we compare ratios of incidents from both the Federal Bureau of Investigation's Supplementary Homicide Reports and the restricted Multiple-Cause of Death files from the National Vital Statistics System to the Fatal Encounters data across coroner contexts in California between 2000 and 2018; we quantify differences descriptively and examine bivariate tests of means. We find significantly greater underreporting of officer-involved deaths in sheriff-coroner counties in both official data sets for all incidents compared with non-sheriff-coroner counties, independently of the period considered. These underreporting differences in the National Vital Statistics System are robust to restricting to gunshot and intentional use of force deaths, the type of incident expected to be less prone to misclassification in that data set. Officer-involved death underreporting in sheriff-coroner counties necessitates further scrutiny. Disparities in officer-involved death reporting suggest political pressure may play a role in classifying deaths.

Undergraduate Education in Forensic Medicine in Germany, Japan, and Korea

Germany, Japan, and Korea have a similar medicolegal death investigation system, the so-called European style, governed by prosecutors for crime investigation and brought into Korea through Japan from Germany. In this system, all physicians must be engaged in postmortem external examination and issue a death certificate for unnatural death. Therefore, education in forensic medicine should be provided to medical students to ensure the ability to determine the cause of death and the manner of death after graduation. However, the quality of undergraduate education in forensic medicine is known to be unsatisfactory in Korea because there is no well-organized nation-based education policy. This study aims to review significant features of the education system for forensic medicine in Germany, Japan, and Korea. Related laws and regulations, standard curriculum, and incorporation of forensic medicine in medical license examination are comparatively analyzed. In conclusion, the Korean education system in forensic medicine has a weak structure for achieving competency in postmortem external examination, while Germany and Japan have sustained relatively concrete frameworks. Practical approaches are proposed for improving education quality, including incorporating forensic medicine into compulsory assessment in the medical licensing examination.

Addendum to previously published article titled "Medico-Legal Death Investigation Systems – Sri Lanka" Sri Lanka Journal of Forensic Medicine, Science &amp; Law, Vol. 13 (Special Issue) 2022 :53-56 DOI: http://doi.org/10.4038/sljfmsl.v13i0.7923 Published on 30th September 2022.

The Sri Lanka Journal of Forensic Medicine, Science &amp; Law (SLJFMSL) is a peer-reviewed, open-access journal published biannually in June and December each year by the Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka.The mission of the SLJFMSL is to stimulate, encourage and empower researchers to publish high quality research in order to promote evidence based practice and provide a platform for researchers to share experiences and knowledge in the fields of forensic medicine, forensic sciences, medical ethics and relevant law. This journal publishes original research papers, reviews, points of view, case reports, technical notes and letters to the editor. The SLJFMSL is committed to maintaining and conforming to the editorial and ethical standards recommended by the International Committee of Medical Journal Editors.SLJFMSL was assessed by the Journal Publishing Practices and Standards framework and was placed at level five (of six) and is currently listed in SLJOL, DOAJ, IMSEAR, NLM Catalogue.

Medico-Legal Death Investigation Systems – Poland

The Sri Lanka Journal of Forensic Medicine, Science &amp; Law (SLJFMSL) is a peer-reviewed, open-access journal published biannually in June and December each year by the Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka.The mission of the SLJFMSL is to stimulate, encourage and empower researchers to publish high quality research in order to promote evidence based practice and provide a platform for researchers to share experiences and knowledge in the fields of forensic medicine, forensic sciences, medical ethics and relevant law. This journal publishes original research papers, reviews, points of view, case reports, technical notes and letters to the editor. The SLJFMSL is committed to maintaining and conforming to the editorial and ethical standards recommended by the International Committee of Medical Journal Editors.SLJFMSL was assessed by the Journal Publishing Practices and Standards framework and was placed at level five (of six) and is currently listed in SLJOL, DOAJ, IMSEAR, NLM Catalogue.

Medico-Legal Death Investigation Systems – New Zealand

The Sri Lanka Journal of Forensic Medicine, Science &amp; Law (SLJFMSL) is a peer-reviewed, open-access journal published biannually in June and December each year by the Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka.The mission of the SLJFMSL is to stimulate, encourage and empower researchers to publish high quality research in order to promote evidence based practice and provide a platform for researchers to share experiences and knowledge in the fields of forensic medicine, forensic sciences, medical ethics and relevant law. This journal publishes original research papers, reviews, points of view, case reports, technical notes and letters to the editor. The SLJFMSL is committed to maintaining and conforming to the editorial and ethical standards recommended by the International Committee of Medical Journal Editors.SLJFMSL was assessed by the Journal Publishing Practices and Standards framework and was placed at level five (of six) and is currently listed in SLJOL, DOAJ, IMSEAR, NLM Catalogue.

Building a Comprehensive Biopsychosocial Database to Identify Underlying Causes of Suicide and Improve Suicide Prevention.

In June, 2022, the United States Department of Veterans Affairs (VA) announced an initiative to reduce death due to suicide in US Veterans. This column is based on a proposal written for that initiative, as well as on an earlier psychopharmacology column in this journal that reviewed the statistics and the genetics of suicide, and the US medicolegal death investigation system. This system is composed of 3137 county coroner or medical examiner offices across the country that are responsible under state and local law for investigating deaths that are not explained by natural causes and are suspicious and/or unattended. Thus, this system gathers data concerning all deaths due to suicide. Currently this death investigation system costs US taxpayers ∼$660 million per year, and it has determined that ∼45,000 Americans die from suicide each year. In the conduct of these investigations, a large amount of data is collected, including biological samples. While the demographic data are reported to the Centers for Disease Control (CDC), little-if anything-is done with the collected biological material beyond its use in determining the cause of death of the individual. The earlier column on this topic advocated for the establishment of a central database to retain and utilize this information to further understand the biopsychosocial causes of suicide, with the goal of preventing suicides. This column describes a proposal submitted to the VA system for how such a system could initially be piloted in a small group of VA medical centers and then expanded to the entire system. This initial effort could then, in turn, serve as a model for expanding such data gathering to the entire US medicolegal death investigation system.

Autopsy findings of post-COVID-19 vaccination deaths in Tokyo Metropolis, Japan, 2021

BackgroundCOVID-19 vaccines have been used across Japan since 17 February 2021, and as of 17 April 2022, 1690 deaths potentially caused by vaccine-related adverse effects have been reported to the Ministry of Health, Labour and Welfare. However, the causal relationship between vaccination and death could not be fully evaluated because of a lack of sufficient information. MethodsAutopsy cases in which deaths occurred within seven days after COVID-19 vaccination in Tokyo Metropolis and were handled by medical examiners were selected (n = 54). Age, sex, vaccine-related information, cause of death, and possible causal relationship between vaccination and death were examined. ResultsThe mean age of the deceased individuals was 68.1 years, and the study sample consisted of 34 males (63.9%) and 20 females (37.0%). Thirty-seven and six individuals received Comirnaty and Spikevax, respectively (68.5% and 11.1% respectively). The manner of death included natural (n = 43), non-natural (n = 8), and undetermined (n = 3). The most frequent cause of death was ischemic heart disease (n = 16). Regarding causal relationships, 46 cases (85.2%) did not show a causal relationship to vaccination, except for myocarditis (n = 3), thrombosis-related death (n = 4), and others (n = 1). ConclusionAlthough many cases of deaths after COVID-19 vaccination in this study showed no definite causal relationship between the vaccination and deaths, some cases showed possible adverse events such as myocarditis. Autopsies are essential for detecting vaccine-related deaths, and the Japanese death investigation system needs to be reinforced from this viewpoint.