Death Investigation Research Articles

An Investigation of Dengue Deaths in Vientiane Capital and Champasack Province, Lao People’s Democratic Republic, 2013

An Investigation of Dengue Deaths in Vientiane Capital and Champasack Province, Lao People’s Democratic Republic, 2013

Forensic Pathology and Unnatural Death Investigations: A Systematic Review of Case Studies and Procedures

Forensic pathology plays a crucial role in investigating unnatural deaths, providing insights that influence legal and judicial outcomes. This systematic review examines case studies and procedures in forensic pathology to identify common methodologies, challenges, and trends in unnatural death investigations. By analyzing a selection of case studies across various regions and types of deaths, including homicide, suicide, and accidental deaths, this review highlights the standard forensic techniques employed—such as autopsy, toxicology, DNA analysis, and imaging technologies—and discusses their impact on case resolution. Findings indicate significant advancements in technology and methodology, yet also reveal challenges such as jurisdictional variations, resource limitations, and inconsistencies in procedure standardization. This review underscores the need for uniform forensic protocols to improve investigative outcomes and legal accuracy. Recommendations include adopting standardized practices, improving resource allocation, and encouraging further research into underexplored areas of forensic pathology. This work aims to provide forensic professionals, policymakers, and researchers with insights that contribute to the refinement of death investigation procedures and support the justice system.

The use of dietary isotopes as a preliminary step in the death investigation of unidentified skeletal human remains in British Columbia, Canada.

In British Columbia, Canada, unidentified skeletal human remains are often recovered by law enforcement or civilians and there is a question if they are modern and of medicolegal significance, or historical or archaeological. We used relatively fast and inexpensive carbon and nitrogen stable isotope analysis of human bone collagen from a selection of these remains (n = 48) combined with a logistic regression model to classify remains as modern, historical, or archaeological. We then confirmed our temporal classification through directly radiocarbon dating each individual and found that we could predict the temporal group with 93% accuracy. In regions where archaeological remains have dietary isotope values distinct from living people, dietary stable isotope analysis can provide a time-, and resource-efficient method to screen cases of unidentified human remains early in death investigation.

Barriers to Family History Collection and Family Medical Screening Recommendation in the Sudden Death in the Young Case Registry.

Sudden death in the young (SDY) poses a public health problem affecting thousands of individuals annually in the United States. The SDY Case Registry utilizes existing infrastructure of death investigation programs, including medical examiner/coroner (ME/C) systems, to enhance understanding of SDY causes and risk factors to inform prevention strategies. This includes identifying and promoting screening recommendations for at-risk family members. To explore barriers to family history collection and familial screening recommendation procedures across Registry sites, nine individuals from seven SDY sites were interviewed. Interviews focused on logistics, methods to address barriers, and recommendations for improvements. Despite variability in practices, data analysis revealed three common themes related to barriers of these processes: (1) timing and grief, (2) lack of family history in medical records, and (3) families lost to follow-up. This study offers insights into these processes within the Registry and sheds light on broader practices within the death investigation domain. Data analysis led to recommendations for the improvement of these practices including the prioritization of three key family history questions during the initial death investigation by a designated individual in each office/system.

Characteristics of Children Ages 1-17 Who Died of COVID-19 in 2020-2022 in the United States.

This study describes characteristics of children ages 1 to 17 years who died of coronavirus disease 2019 (COVID-19) in 2020 to 2022 and whose deaths were reviewed by child death review (CDR) teams across the United States. We used data in the National Fatality Review-Case Reporting System to examine children who died of COVID-19. Deaths were determined because of COVID-19 from death certificates or CDR determinations. A total of 183 children 1 to 17 years old who died of COVID-19 were reported in the National Fatality Review-Case Reporting System. One-third (33%) were 15- to 17-year-olds, and 26% were 1- to 4-year-olds. Fifty-six percent were reported as male, 54% white, 24% Black, and 18% Hispanic ethnicity. Physicians declared cause of death in at least 82% of deaths. More than two-thirds (68%) had a medical condition (excluding COVID-19) at time of death. The most common conditions were nervous system disorders (19%), congenital disorders (14%), obesity (12%), respiratory disorders (12%), and neurodevelopmental disorders (10%). Of children with an underlying condition, 35% had 3 or more conditions. Less than half (42%) had contact with a health care provider within a month of their death; and three-fourths died within 14 days of exposure. This study describes the demographics, death investigation findings, and medical conditions of children who died of COVID-19. The results highlight the short timeline between COVID-19 exposure and death. Pandemic planning that prioritizes prevention efforts and timely access to effective medical care may result in saving children's lives.

Unexplained Infant Deaths Without Unsafe Sleep Factors: 2011 to 2020.

To describe sudden unexpected infant deaths (SUIDs) occurring in safe sleep environments and explore differences in selected characteristics. We examined SUID from 22 jurisdictions from 2011 to 2020 and classified them as unexplained, no unsafe sleep factors (U-NUSF). Data were derived from the Sudden Unexpected Infant Death and Sudden Death in the Young Case Registry, a population-based Centers for Disease Control and Prevention surveillance system built on the National Center for Fatality Review and Prevention's child death review program. SUID classified as U-NUSF included infants who were (1) awake, under supervision, and witnessed to become unresponsive or (2) found unresponsive in a safe sleep environment after sleep (unwitnessed). We calculated frequencies and percentages for demographics, birth and environmental characteristics, medical history, and death investigation findings. Most of the 117 U-NUSF SUID occurred before 4 months of age. Witnessed deaths most commonly occurred at <1 month of age (28%), whereas unwitnessed deaths most commonly occurred at ages 2 to 3 months (44%) Among all U-NUSF, 69% occurred in the infant's home (62% witnessed, 77% unwitnessed). All unwitnessed deaths occurred in a crib; most witnessed deaths occurred while being held (54%) or in a car seat traveling (18%). Most infants (84%) had no history of abuse or neglect. Abnormal autopsy findings were reported in 46% of deaths (49% witnessed, 42% unwitnessed). Characterizing these deaths is key to advancing our knowledge of SUID etiology. Our study revealed a heterogeneous group of infants, suggesting physiologic, genetic, or environmental etiologies.

The ASAP study: association of atherosclerosis with pathobiology in a caucasian cohort—a study of 3400 autopsy reports

Cardiovascular plaques result from atherosclerosis. Autopsy investigations of unnatural deaths provide atherosclerosis research. A Central European cohort was studied in a cross-sectional study to determine the origin of atherosclerosis and the link between arterial status and pathobiological variables. This study incorporated 3400 autopsy reports (n = 2318 men; aged 0─96 years; 1928─2010) of persons who died by unnatural causes (suicide, homicide, accident). Age, sex, BMI, abdominal fat thickness, and arterial status of six vascular areas were gathered. The arterial state was divided into five subgroups according to its status. BMI declined from 22.82 kg/m2 in 1931 to 18.43 kg/m2 in 1947, then increased to 27.88 kg/m2 in 2005. Atherosclerotic degeneration begins in the abdominal aorta, then the thoracic, coronary, carotid, ascending, and cerebral arteries. All blood arteries deteriorated faster in men than women until 55. Abdominal aorta damage was the fastest in both sexes. Age is the biggest predictor of atherosclerosis, followed by sex, overweight, and abdominal thickness, according to logistic regression. This is the largest Central European autopsy investigation of six vascular areas. Both sexes develop atherosclerosis in the abdominal aorta in the first decade of life. Being overweight increases the risk. The findings of this study aid healthcare providers in personalized therapy.

A natural language processing approach to detect inconsistencies in death investigation notes attributing suicide circumstances

BackgroundData accuracy is essential for scientific research and policy development. The National Violent Death Reporting System (NVDRS) data is widely used for discovering the patterns and causing factors of death. Recent studies suggested the annotation inconsistencies within the NVDRS and the potential impact on erroneous suicide-circumstance attributions.MethodsWe present an empirical Natural Language Processing (NLP) approach to detect annotation inconsistencies and adopt a cross-validation-like paradigm to identify possible label errors. We analyzed 267,804 suicide death incidents between 2003 and 2020 from the NVDRS. We measured annotation inconsistency by the degree of changes in the F-1 score.ResultsOur results show that incorporating the target state’s data into training the suicide-circumstance classifier brings an increase of 5.4% to the F-1 score on the target state’s test set and a decrease of 1.1% on other states’ test set.ConclusionsTo conclude, we present an NLP framework to detect the annotation inconsistencies, show the effectiveness of identifying and rectifying possible label errors, and eventually propose an improvement solution to improve the coding consistency of human annotators.

Death investigation and coroners’ inquests: Evolution and improvements

Death investigation and coroners’ inquests: Evolution and improvements

Comparative Analysis of Drowning Index: Relevance in Drowning Deaths versus Non-Drowning Asphyxial Deaths

Drowning remains a significant cause of mortality worldwide, necessitating accurate diagnostic tools for forensic investigation. This paper conducts a comparative analysis of the Drowning Index (DI) to ascertain its relevance in distinguishing drowning deaths from non-drowning asphyxial deaths. Drowning deaths present a challenge for forensic pathologists, because the autopsy findings may occur in many non-drowning scenarios. Previous studies have attempted to identify patterns in organ weights that may be specific for drowning. The drowning index has been defined as the weight ratio of the lungs and pleural effusion fluid to the spleen. We compared the lung and pleural effusion weight, spleen weight, and DI from 124 autopsies of asphyxia deaths including both drowning deaths and non-drowning asphyxia deaths such as hanging, strangulation, suffocation and mechanical asphyxia at the department of Forensic Medicine and Toxicology at the Gandhi Medical College, Bhopal from January 2021 to August 2022. Findings highlight the potential utility of the DI as a valuable adjunctive tool in forensic investigations, providing insights into its comparative efficacy in differentiating drowning from other modes of asphyxial deaths. Such insights are critical for enhancing accuracy in forensic diagnoses and contributing to advancements in medicolegal death investigations.

What Has the Sudden Unexpected Infant Death and Sudden Death in the Young Case Registry Learned About Consenting Families for DNA Banking and/or Genomic Research?

Since 2015, the Sudden Unexpected Infant Death (SUID) and Sudden Death in the Young (SDY) Case Registry has characterized sudden and unexpected deaths among young people (0-20 years). Families may provide informed consent to save biospecimens for banking and/or genomic research. We reviewed all consent-eligible cases to describe the frequency, time from death to consent, type (paper, phone, or electronic), and staffing method (Medical Examiner Office-based bereavement counselor vs outsourced genetic counselor). Of 5438 cases from January 2015 to January 2022, 3498 (64%) were eligible for consent and 391 (11%) were successfully consented. Half (54%) were obtained within 60 days of the death, 39% within 48 hours. Most were paper based (73%); 23% were obtained by phone, and 4% electronically. Consent rates varied by site from 3% to 66%. Higher consent rates were achieved within a Medical Examiner Office by a social worker or death investigator. Only 3% of consents attempted by a contracted genetic counselor were successful. Identified barriers include lack of available contact information, inability to reach family using the collected information, and lack of response when contacted. Consent rates were highest shortly after death when families were contacted by the Medical Examiner Office as part of bereavement outreach.

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.

B-257 Dont go breaking my heart: use and misuse of beta-blockers in clinical and forensic casework (2019-2023)

Abstract Background Beta-adrenergic antagonists, or beta-blockers, are commonly prescribed for the treatment and prevention of a variety of cardiovascular issues and other health conditions. These include, but are not limited to heart failure, heart rhythm disturbances, high blood pressure, hypertension, anxiety, asthma, glaucoma, and migraines. Beta-blockers work by blocking access to beta-receptors, which then enhance or inhibit cellular activity and result in dilating blood vessels and relaxing the heart muscle. When misused, accidentally or intentionally, serious adverse effects including dizziness, seizure, heart failure, QTc prolongation, coma, and death can occur. In routine toxicology testing, beta-blockers are often reported qualitatively, which likely underestimates the reporting of related adverse events. We performed a retrospective review to evaluate quantitative levels of beta-blockers in blood and identify trends of potential misuse. Methods We queried our laboratory’s data management system from 2019-2023 for reported findings of beta-blockers in blood. Analytes were quantified with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Results were analyzed using Microsoft Office software. Results Blood results and a comparison of known therapeutic and adverse concentrations are shown in Table 1. Age and sex were reported in 50% and 74% of cases, respectively. Average age ranged from 43 years old (propranolol) to 59 years old (atenolol and metoprolol), without major differences between sexes. Overall use of beta-blockers was split evenly between men and women. Importantly, each analyte provided examples which far exceeded known therapeutic levels, with several cases submitted as potential overdoses. Conclusions Since beta-blockers are generally reported qualitatively during routine toxicology testing, concentrations are unknown. Quantitative testing has shown that beta-blocker concentrations often exceed known therapeutic ranges, which can lead to adverse effects and fatal outcomes. Physicians and death investigators should be aware of these adverse effects and the need for specialized testing in the event of suspected beta-blocker toxicity.

Guidelines for Scrutiny of Death Associated With Surgery and Anesthesia.

The death of a patient in the operating room frequently causes great distress to the patient's family, and the surgical team members who performed the procedure typically feel uneasy about it afterward. Anesthetic death is characterized as a death that happens 24 hours after anesthesia is administered and is caused by anesthetic-related factors. However, death can come much later because of its complications. This review thoroughly explains mortality resulting from surgery and anesthesia, including autopsy reports, investigative data, analytical techniques, and conclusions. Following surgery and anesthesia-related death,in case of death after surgery, an autopsy determines the cause of death and if the procedure had any impact on it. Individuals who pass away during or after surgery may do so for a wide range of reasons, such as a generally natural condition, an early or late surgical complication, an anesthetic problem, or an error during the operation or anesthesia. The pathologist should take the results of the examination into account while looking into an anesthetic death. In the majority of anesthesia-related deaths, autopsies reveal little diagnostic informationwith the absence of an underlying cause of death. The analyses help determine and estimate the dosage of medication given, as well as the amount of anesthetic agent overdose provided before death. The best consensus opinion to provide the investigative authorities and courts of law for the cause of death investigation may come from a discussion amongst forensic pathologists, surgeons, and anesthetists. In conclusion, the family and friends of the deceased are greatly affected by an unexpected or unexplained death, and the organizations entrusted with determining the cause of death bear a great deal of responsibility. Science and technology are becoming more and more important in death investigations. Following precise and well-founded procedures is one of the science's defining characteristics.

Comprehensive statistical analysis of causes of death and histopathological diagnosis in medico-legal investigations of sudden cardiac deaths

Background and objectives. Sudden cardiac deaths (SCDs) have a significant impact worldwide. Its distribution trends may vary across different communities globally. Consequently, investigating sudden cardiac deaths necessitates a regional, multi-faceted approach. This study aims to ascertain the pathological background of the patients who died in the context of sudden cardiac death and analyze it statistically to generate some trends and define the occurrence of disease. Materials and methods. We conducted a retrospective analysis of the causes of death for cases from the Legal-Medicine Department of Maramures County, Romania, between 2021 and 2023. From this cohort, we identified and selected cases of SCD and conducted a statistical analysis of the number of cases, gender distribution, age group distribution, and the underlying cardiac pathology that led to this outcome. Results. 276 sudden cardiac deaths (SCD) were identified from 1,186 autopsies. Males accounted for 75% of SCD cases, with a mean age of 58.8 years. Advanced myocardial fibrosis (41.6%) was the most frequent cause, followed by coronary artery disease (18.12%) and acute myocardial infarction (17.4%). Males had significantly more AMI cases (p = 0.045), while females had more coronary artery disease and advanced myocardial fibrosis, though not statistically significant. Conclusions. Sudden cardiac death predominantly affects males, particularly those aged 51–60, with advanced myocardial fibrosis being the most common cause. The gender difference in AMI prevalence was significant, highlighting the need for targeted prevention and diagnostic improvements. Further research in liaison with experts in all fields is required.

Age estimation of Phormia regina pupae based on ATR-FTIR and chemometrics

Accurate postmortem interval estimation is vital in the investigation of homicides, suicides, and accidental deaths. It is key in narrowing suspect lists, improving crime-solving efficiency, and offering solace to bereaved families. The intra-puparial period, comprising about half of a fly’s developmental cycle, presents challenges for morphological age estimation. External changes are limited to color shifts and the appearance of respiratory horns on the puparium only within several hours after pupariation, while detailed internal development analysis often requires invasive methods like removing the puparium, which can be damaging. Additionally, these techniques usually depend on a forensic entomologist’s expertise, which lead to subjective biases. This study employed attenuated total reflection-fourier transform infrared spectroscopy, a rapid, non-destructive method for analyzing proteins, chitosan, and chitin in puparia. Data showed a consistent reduction in the concentration of the amide I band within the puparium during the intra-puparial development at five constant temperatures (19 °C, 22 °C, 25 °C, 28 °C and 31 °C). This trend in the spectral data effectively distinguishes pupae at various stages of intra-puparial development, facilitating precise age estimation, which is critical for the estimation of the minimum postmortem interval (PMImin). Finally, this work combined the total reflection-fourier transform infrared spectroscopy with chemometric analysis and successfully developed a partial least squares discriminant analysis model and a random forest model, with accuracies of 88 % and 81 %, respectively. These models enable the non-invasive age estimation of P. regina in its intra-puparial period, a stage traditionally difficult to assess morphologically, thus laying the groundwork for PMImin estimation using fly pupae.

Impact of ante-mortem fluoxetine administration on estimation of post-mortem interval and insect activity in rabbit carcasses

BackgroundIncreasing the number of drug-related deaths has affected medico-legal death investigations. Drugs within a corpse have a great impact on the insects’ development rate which in turn will affect the rate of post-mortem decomposition and the estimation of the post-mortem interval. This explains the importance of the application of forensic entomotoxicology, which studies the impact of drugs and toxins on the development and succession patterns of insects. The current study aimed to determine the impact of fluoxetine, one of the selective serotonin reuptake inhibitors (SSRIs), on post-mortem decomposition, insects’ attraction, and its pattern of succession on carcasses. Sixteen healthy male and female Oryctolagus cuniculus rabbits were chosen to be included in this study. They were divided into a treated group of eight rabbits received oral fluoxetine for 28 days and a control group of eight rabbits received oral distilled water for 28 days. After oral administration of 10 mg/kg/day of fluoxetine and distilled water for 28 days, rabbits were sacrificed, and carcasses were transmitted to the roof of Research and Training Centre on Vectors of Diseases at faculty of Sciences, Ain Shams University, for following up the post-mortem decomposition process and insect’s attraction to carcasses for 60 days. Carcasses were put in two outdoor sites that differ in temperature to assess the effect of temperature on decomposition process.ResultsFluoxetine administration has accelerated the rate of post-mortem decomposition in the treated carcasses by 3–9 days compared to the control ones and affected the numbers and species of attracted insects, while it had no effect on the insects’ succession patterns. Exposure of carcasses to direct sunlight has accelerated the rate of decomposition in comparison to that of carcasses put in shade in the overall period of decomposition by about 14 to 16 days.ConclusionsFluoxetine has an important and effective role in post-mortem decomposition and estimation of post-mortem interval (PMI) and has a great impact on attracted insects to the treated carcasses. Temperature has a great effect on the rate of decomposition of carcasses. Higher temperature accelerates the rate of post-mortem decomposition.

A review of the estimation of postmortem interval using forensic entomology.

The postmortem interval (PMI) is a crucial factor in death investigations. For PMIs exceeding 24 h the forensic pathologist must turn to other specialties that focus on decompositional ecology of animals, including humans. Primary among these specialties is forensic entomology. Here, we review the importance of forensic entomology in estimating the PMI, and we examine the factors that influence these estimates. Among key concerns are environmental factors, especially temperature, and aspects of insect biology. Additionally, we examine current methods used for calculating PMI based on insects and their development.

Photon-counting CT for forensic death investigations-a glance into the future of virtual autopsy.

This article explores the potential of photon-counting computed tomography (CT) in forensic medicine for a range of forensic applications. Photon-counting CT surpasses conventional CT in several key areas. It boasts superior spatial and contrast resolution, enhanced image quality at low x-ray energies, and spectral imaging capabilities that enable more precise material differentiation. These advantages translate to superior visualization of bone structures, foreign bodies, and soft tissues in postmortem examinations. The article discusses the technical principles of photon-counting CT detectors and highlights its potential applications in forensic imaging, including high-resolution virtual autopsies, pediatric forensic CT, trauma analysis, and bone density measurements. Furthermore, advancements in vascular imaging and soft tissue contrast promise to propel CT-based death investigations to an even more prominent role. The article concludes by emphasizing the immense potential of this new technology in forensic medicine and anthropology.

Forensic entomology in homicide cases: study of a corpse found inside a buried vehicle.

Forensic entomology plays a crucial role in death investigations, particularly in estimating the postmortem interval (PMI). This study presents a forensic entomology case involving a corpse found in a buried utility vehicle. The victim was in an advanced state of decomposition, with autopsy findings revealing gunshot wounds. Cadaveric fauna was collected at the scene and during the autopsy. The analysis revealed a diverse insect community, with predominance of Compsomyiops fulvicrura and Piophila casei. The time of development of species like Dermestes maculatus and Necrobia rufipes was used to estimate the minimum PMI. The presence and low abundance of Calliphora vicina, a species preferring lower temperatures, shed light on the seasonal conditions at the time of death and suggested possible body concealment shortly after death. This research is the first to report insects as evidence in a corpse found in a buried vehicle and contributes to the body of knowledge in forensic entomology. The study also suggests that the use of entomological evidence can provide additional information about the season in which the body was concealed, making it a valuable tool in death investigation and crime scene reconstruction. Finally, it emphasizes the need for proper sampling, expert identification, and close collaboration between forensic entomologists and pathologists.