Local Coroner Research Articles

Pediatric Firearm Trauma on the Rise: A Retrospective Review of Over 1,100 Cases in 12 Years at One Center

BackgroundGunshot injuries are the leading cause of death among children in the United States. The goal of this study was to better understand if certain age groups, mechanisms of injury, and type of firearms were associated with the increasing rates of pediatric gun-related trauma. We hypothesized that the extremities were disproportionately targeted when compared with the random likelihood of striking specific body-surface areas. MethodsThis study includes pediatric firearm-related injury (FRI) patients who presented to a single free-standing level 1 pediatric hospital or died at the scene from 2010 to 2021. The hospital data was collected prospectively as part of a level 1 trauma system electronic database. Death data was collected from the local coroner's office. ResultsBetween 2010 and 2021, 1,126 pediatric FRI occurred in the geographic region studied. Demographic information available for 1,118 patients showed that 897 (80.23%) were male, and that black individuals had a statistically significant increased rate of FRI compared with white or Hispanic individuals. Mean age was 13.69 years. Most injuries were caused by handguns. ConclusionsThis data could help leaders design strategies to combat the violence, such as legislation that limits handgun access to all, especially children, and mandates safe storage of handguns. Gun-lock programs, universal background checks, and firearm-ownership education also might help stem this tide of violence. Level of EvidenceLevel II Prognosis study.

A review of findings from placental histology in cases of stillbirth following the amendment to the Coroner's Act.

An amendment to the 1962 Coroner's Act in the Republic of Ireland mandated that all stillbirths and neonatal deaths were to be reported to the local coroner's office. In response to this, the bereavement team and department of anatomic pathology modified the pathway for placental examination following stillbirth and reporting deaths to the coroner. This paper is a review of the effect of this practice. This study is a review of all cases of stillbirths for 9months following the amendment of the Coroner's Act. A descriptive, exploratory design was used involving a retrospective chart review. Twenty-nine cases of stillbirth occurred during the study period. In cases where a placental examination was performed (n = 22), a cause of death was identified in the placenta or cord for seventeen (68%) of these cases. Seven cases had a consented autopsy with six cases confirming the initial diagnosis made at the time of gross placental examination. In one case, the cause of the stillbirth remained unexplained following placental examination and a full autopsy. No new information was gained from the autopsy in these seven cases. A further two cases had an autopsy directed by the coroner; the cause of death in these cases will be decided by the coroner. The introduction of the pathway has improved the care provided to bereaved parents by providing parents with timely information about the potential cause of stillbirth and thereby reduces the need for an autopsy examination.

Teens, Drugs, & Vegas: Toxicological surveillance of illicit prescription and illegal drug abuse in adolescents (12–17 years) using post-mortem data in Clark County, Nevada from 2005 to 2015

Illegal drug abuse, particularly prescription drug abuse is a growing problem in the United States. Research on adolescent drug abuse is based on national self-reported data. Using local coroner data, quantitative prevalence of illegal substance toxicology and trends can be assessed to aid directed outreach and community-based prevention initiatives. Retrospective analysis was conducted on all cases aged 12–17 years referred to the Office of the Medical Examiner, Clark County from 2005 to 2015 (n = 526). The prevalence of illegal opioid use in this population was 13.3%. The most commonly used drug was tetrahydrocannabinol (THC) in 29.7%. Illegal-prescription opioids and benzodiazepines were used approximately 1.7 times as much as all other illegal-drugs, excluding THC combined. The largest proportion of illicit prescription drug users were accidental death victims (p = 0.02, OR = 2.02). Drug trends by youth are ever evolving and current specific data is necessary to target prevention initiatives in local communities.

From Memory to Memorial: Shanksville, America, and Flight 93

From Memory to Memorial: Shanksville, America, and Flight 93

Adjudicating Death: Professionals or Politicians?

Variation exists in how death examinations take place in the United States. In some counties and states decisions about autopsies and the issuance of death certificates are made by a local coroner who often needs nothing more than a high school diploma to run for election to the job of coroner. In other counties and states, an appointed medical professional performs the death examination. We provide preliminary tests of the difference in performance between death examination offices run by appointed medical professionals compared with elected coroners. We find that death examiner offices in elected coroner states are less likely to be accredited by the major national organizations and correlate with greater amounts of autopsy related litigation. We also find some evidence that the historical shift from elected coroners to appointed medical professionals was more likely in states with less of a preference for direct democracy as proxied by the system of state supreme court judge selection.

Suicide prevention in primary care: taking a risk and saving lives

Torbay council’s public health department has audited suicides since 2009. With the support of the local coroner, this has produced a wealth of information that has enabled better targeting of efforts to prevent suicide in the local area. Although the information produced reflects national trends, innovative community work was necessary to support the primary healthcare team once risk factors had been considered. Breaking through the myths and the stigma concerning suicide is necessary to understand that it is preventable. Few people who take their lives have contact with mental health services before they die, so the focus of prevention must rest with the GP and primary healthcare team.

County Coroners and Their Role in the Heart of the Opioid Epidemic.

As drug- and opiate/opioid-related deaths continue to rise in the Midwest, we must look at how the type of death investigation in these areas is affected and taxed by the increase. Many states with a large rural component rely on a local coroner system, where death investigation lacks uniformity and requirements for coroner investigative personnel are extremely variable. This has mixed implications for communities and potentially affects law enforcement and prosecution, data collection, and public policy. Both coroner and medical examiner systems benefit from strong leadership, properly trained personnel, and fiscal support. However, operational differences amongst jurisdictions should be addressed so that all stakeholders ultimately receive optimal data. This paper discusses the coroner system of death investigation in one Midwest state (Ohio) in the context of the region's burgeoning opiate/opioid epidemic and suggests opportunities for improvement.

Preventive pathology revisited

A number of years ago, a paper in the journal Injury Pre-vention focused on the remarkable scope that forensicpathologists have of evaluating injuries in the morgue,clarifying dangerous circumstances and of formulatingproposals to prevent similar deaths in the community [1].The paper was entitled ‘Preventative Pathology’ and wasan attempt to dispel the time-honored perception ofpathologists that while they may know everything, they areinevitably too late. Given the 15 years that has passed sincethe publication of that paper, it is perhaps timely to re-evaluate the role of pathologists in injury prevention andcommunity safety and in the evolution of preventivepathology.There is no doubt that forensic pathologists have a keyposition in the examination of preventable deaths due totrauma [2], and the paper by Bamber et al. [3] in this issueof the journal exemplifies this. While the current author hassimilarly focused on aspects of childhood injury and death,the scope is however much wider and includes not onlyaccidents at any age but also suicides, homicides, andcertain heritable and non-heritable diseases. Examples ofsuccesses over the past decade include evaluation of infantand early childhood deaths in shared sleeping situationsand in dangerous cribs, with recent research supportingaccidental suffocation as a cause of some of these deaths,and the remarkable reduction in cases of sudden infantdeath syndrome; the latter based on information gained atdeath scene examination [4]. The rapid identification ofnew types of illicit drugs and methods of suicide in adultsare other examples [5, 6]. Identification of conditions witha genetic component may have great significance to indi-vidual and extended family members.A requirement for an effective preventive pathologyprogram to work is the ability to ensure that informationthat is obtained from the morgue is appropriately andeffectively disseminated to those in the community whocan most benefit from it. This may be relatively straight-forward if forensic pathologists have a functional rela-tionship with the local coroner, or if medical examiners’offices have associations with local hospitals, injury anddisease prevention organizations, police, or product safetygroups. However, sometimes alerting family members tothe potential for heritable disease is not straightforward, asautopsy reports may not go directly to the family ofdecedents in all jurisdictions [7].Unfortunately, many forensic pathologists are still notactive in injury and disease prevention programs. Whilethere has been a reasonable representation of pathologistson mortality review committees, this has often involvedcompiling lists of lethal episodes without taking the furtherstep of attempting to understand how to reduce theoccurrence of such fatalities. Given that many lethal acci-dents result in cases bypassing emergency rooms andhospitals, this may represent a lost opportunity for pre-vention. In the worst case scenario, bodies may be exam-ined, autopsied, and then buried, taking their potentiallyvaluable lessons with them to the grave.One of the ongoing themes at forensic meetings over theyears has been the failure to recruit young physicians into

All that vomits is not gastroenteritis

The sudden deaths of four children are described. In each case, the predominant symptom was vomiting. In two of the four cases, medical attention was sought and each child was discharged from care, only to re-present later when in a critical condition. All cases were referred to the local coroner for autopsy. All cases highlight the difficulties in making an accurate diagnosis in sick children where the presenting symptom is vomiting. The cause of vomiting in each of the cases was not from gastroenteritis as thought most likely by treating medical staff, but from a surgical cause in three cases and an infectious cause in the fourth case.

Coroners could provide a voice for bereaved parents

Members of your readers panel were asked if the deaths of all young children and babies in hospital should be reported to the local coroner for investigation (reflections July 7). As a nurse and the bereaved mother of twin babies, I feel compelled to give you my opinion.

Readers panel-why did baby die?

Should the deaths of all young children and babies in hospital be reported to the local coroner for investigation? We asked our readers panel

A comparison of suicide and undetermined deaths in Cornwall across national and local agencies

We looked to evaluate the reporting pathways and statistics between relevant stakeholders for reporting suicides and undetermined deaths in Cornwall. We checked on the correlation of the numbers provided for suicides and open verdicts given by different national and regional agencies including the local Coroner's office, Office of National Statistics (ONS), Cornwall Partnership NHS Trust (CPT) and The National Confidential Inquiry (NCI) into suicides for Cornwall. We examined the data of suicides and open verdicts presented by these agencies between the years 2000 and 2002. Our study shows that the data transfer between the relevant agencies (local Coroner, ONS, CPT and NCI) can be inaccurate. These inaccuracies not only prevent establishment of clear records but could also impact on policy decisions. It is also important to recognize that NHS trusts involved in mental health are being evaluated on their record on suicide prevention which in some senses is the most important outcome measure, thus making it important for inspecting bodies to look out for and take account of different figures from different agencies.

Emergency management and mass fatalities: Who owns the dead?

Mass fatality incidents are always unexpected and put a sudden stress on local response agencies to cooperate and share resources to accomplish tasks that are outside their normal activities. Lines of legal authority are often conflicting when two or more agencies are statutorily in charge. Within the USA, the local coroner system is almost universally delegated as responsible for all involved tasks including body recovery, yet the coroner is almost always the smallest responding agency, with the smallest labour pool from which to draw and the least experience of formal Incident Command System (ICS) procedures at large incidents. This paper explores the many tasks required following a mass fatality incident and the necessity for pre-event written agreements to be negotiated between local, state and federal agencies to ensure that material and personnel can be readily shared and reimbursed without bureaucratic misunderstanding in order to accomplish known objectives. Also explored are potential National Incident Management System conflicts in applying unified command to situations where legal authority and level of commitment are not synonymous.

Though Rare, Long-Term Care Autopsies Are Valuable

Though Rare, Long-Term Care Autopsies Are Valuable

Who to report to the coroner? A survey of intensive care unit directors and Her Majesty's Coroners in England and Wales.

We performed a postal survey to assess the ability of intensive care unit directors and Her Majesty's Coroners to recognise deaths that should be reported to the local coroner. The survey questionnaire consisted of 12 hypothetical case scenarios. Coroners were significantly better at identifying reportable deaths than intensive care unit directors (median correct recognition scores of 11 (interquartile range 9.25-11) vs. 8 (interquartile range 7-10), respectively, p < 0.01). Deaths associated with an accident, medical treatments, industrial disease, neglect and substance abuse were significantly under-reported by intensive care unit directors (p < 0.01). Results show that significant numbers of deaths on intensive care units in England and Wales may not be being referred for further investigation, and that wide variation in local coroners' practices exists. Improvements in postgraduate medicolegal education about deaths reportable to a coroner are required. National regulations need to be more detailed and standardised so that regional variation is eliminated.

Postmortem examinations using magnetic resonance imaging: four year review of a working service

Magnetic resonance imaging is useful in postmortem examination of neonates.1 As an alternative to invasive autopsy, the Jewish community asked for magnetic resonance imaging to be used in postmortem examinations...

Urban residential fire and flame injuries: a population based study

Background—Fires are a leading cause of death, but non-fatal injuries from residential fires have not been well characterised. Methods—To identify residential fire injuries that resulted in an emergency department visit,...

Contributory factors to traffic accident deaths identified at coroner's inquest.

Road traffic accidents (RTAs) are an important public health problem and the collection of local information is central to successful accident initiatives in a district. As the local coroner is responsible for investigating accidental deaths, the coroner's inquest files are a potentially useful source of information in developing a district strategy to reduce accidents. A consecutive series of fatal RTAs occurring within the city of Liverpool (1990-1992) were identified and the inquest records of the city coroner reviewed retrospectively to describe the local pattern of fatal RTAs and identify contributory factors. A total of 95 deaths were reviewed. Deaths predominantly involved pedestrians (72) and private cars (70), on roads where the speed limit was 30 m.p.h. (75), often on the main arterial roads of the city (53). Important contributory factors included alcohol consumption by the fatality (31), unsafe driving (31), unlit street lighting at night (16), and pedestrians failing to look (12). Both alcohol consumption and unsafe driving prominently involved younger adult males. More than two-thirds (64/95) of deaths had one or more contributory factors identifiable from inquest records. Coroner inquest records provide a useful source of information to identify opportunities and priorities for preventing fatal RTAs in a district. The subsequent accident strategy for Liverpool, part of the City Health Plan, advocates a co-ordinated approach that includes engineering measures to reduce vehicle speeds and protect pedestrians, measures to address driver attitudes, and the enforcement of current legislation in relation to alcohol and speeding.

Analysis of necropsy request behaviour of clinicians.

To develop a necropsy related audit system to record accurate information in relation to necropsy requests, necropsy rates and coronial referrals. A simple audit form was used to record detailed necropsy related data via an integrated questionnaire design and data entry system based on available optical image scanning technology. The system recorded the numbers and locations of deaths, referrals to the coroner, clinical necropsy requests, hospital and medicolegal necropsies, the grade of clinician involved in these processes, and the identity of the consultant in charge of the case. The overall, hospital and medicolegal necropsy rates were calculated by individual consultant, specialty and for the whole hospital. Necropsy request rates and coronial referral rates were also calculated and these data were related to the grade of clinician. All data were available on a monthly or an accumulative basis. Of 1398 deaths, 534 (38%) were discussed with the local coroner's office and 167 of these were accepted for further investigation. House officers and senior house officers referred over 80% of all cases, whereas consultants referred only 2%. There were no significant differences in case acceptance rates by grade of clinician. Clinicians made 307 hospital necropsy requests (overall hospital necropsy request rate 22%). House officers made 65% of all necropsy requests. Consultant necropsy requests represented 13% of all requests. There were no significant differences in necropsy request success rates by grade of clinician. The referral of cases to coroners and clinical necropsy requests are still being inappropriately delegated to the most junior clinicians. This study illustrates the type of useful information which can be produced for individual clinicians, specialty audit groups and pathology departments using a simple necropsy related audit system.

Waiting for a Disaster to Happen

After a hospital disaster exercise held in 1993 in London, Ontario, questions arose about the disposition of fatalities and the provision of pathology services. Review of local disaster plans revealed that these issues were not adequately addressed. During 1994, discussions between pathologists representing the three local hospitals, police, disaster planners and the Regional Coroner focused on a notification process and the capabilities of the London teaching hospitals in the event of a multiple fatality incident. The number of deaths examined locally would be influenced by many factors including the nature of the disaster and scene, personnel and facilities. Pathologists would not only perform autopsies but also could be requested to assist in body recovery. In disasters that exceed local capabilities Ontario's Chief Coroner requires the bodies of the deceased and all associated investigation be transferred to the central Forensic Pathology Unit in Toronto. Local pathologists and coroners should still continue to participate in local disaster planning and multiple fatality exercises.