Medicolegal Death Investigation Research Articles

Current Medico-legal Death Investigation System in China

Medico-legal death investigation in China has a long history that can be traced back to the Chhin era in the third century BC. We conducted a national study on the current medico-legal death investigation system in China. Our study showed that, at present, medico-legal death investigations in China are conducted by c. 12,000 forensic medical experts mainly within five relatively independent agencies: the police organizations, the prosecutors' offices, the departments/divisions of forensic medicine/science in medical colleges and universities, the Institute of Forensic Science in the Ministry of Justice, and the government or private forensic societies. Owing to China's large population and area, the medico-legal death investigation is largely based on the administrative divisions. There is a wide variation in the scope, extent, and quality of investigations among the agencies and at the different levels of county/district, municipal, and provincial governments. This article gives a general overview of medicolegal death investigation in modern China.

Essential Medicolegal Death Investigation Services: Standardization of a Survey Instrument Based on the Essential Public Health Services

The National Academy of Sciences recommends that states assess the performance of medicolegal death investigation agencies. To aid in performance assessment, we adapted an instrument based on the CDC's 10 Essential Public Health Services by translating the terminology to that of essential medicolegal death investigation services. This produced a survey that could be used to standardize reporting practices and services of agencies. To validate the instrument, a stratified random sample of 12 death investigation chiefs in 12 states was interviewed. This sample represented both medical examiner and coroner jurisdictions within the varying medicolegal structures. A cognitive testing process elicited how well participants could respond to and interpret the survey questions. The response was favorable in that the respondents agreed that given specific revisions toward question clarification, the instrument would be a useful and relevant tool for assessing system performance.

Giving the evidence

The output of the work of a forensic pathologist could be distilled into the delivery of information to a range of justice agencies and in particular to the forum of a court or other judicial or quasi judicial tribunal. The increasing complexity and knowledge base of forensic and medical science and the growing emphasis on ‘evidence based medicine' poses significant challenges to the delivery of technical oral testimony in legal proceedings. Indeed these issues also raise problems in the production of medico-legal reports that suitably demonstrate the results of the tests undertaken in a medico-legal death investigation. New technology in the form of autopsy CT and MRI scans as well as superimposition techniques in anthropology and dentistry present particular challenges when raised in evidence, not so much in their acceptability by the court, although this is an ongoing issue, but with regard to how such virtual 3D data can be admitted and subjected to legal scrutiny through the process of cross examination. How juries receive and comprehend such evidence is also an unknown quantity. Are they overawed by the technology so that they assume the pathologist must be correct or are they confused by it and therefore dismiss it. This joint session culminating in a ‘Hot Tub' expert panel will review the state of the law with regard to expert evidence and these new technologies and further explore the way in which pathologists can use visual aids to assist in getting their message across to the Judge and Jury. The various linguistic perils of delivering oral testimony will also be discussed together with the risks associated with uncertainty, ‘just my opinion' and getting it wrong! Quality assurance systems now mandatory in all medical laboratories to assure the quality of the laboratories results have yet to find an official place with respect to forensic pathology testimony. Given the new technologies now being implemented in forensic pathology how long can this state of affairs continue?

Age estimation and the medial clavicular epiphysis: analysis of the age of majority in an Australian population using computed tomography

This study was designed in order to assess the suitability of clavicular development in discriminating whether or not an individual has reached the age of 18 years. The development of the medial clavicular epiphysis was examined in an Australian population using computed tomography as the imaging modality. The sample consisted of individuals who were admitted to the Victorian Institute of Forensic Medicine, Melbourne, Australia, for the purposes of medico-legal death investigation. Comparisons were made with similar studies conducted on different populations in other countries, which revealed that the Australian population reaches maturity earlier, and the level of left/right asymmetry is higher than in other studies. The high degree of variation in fusion times is discussed, and the consequent effect upon the ability to use this epiphysis as a tool for determining if an individual has reached the age of 18 years is analysed. If an individual in this population has completely fused clavicles at stage 5, then for males they will be at least 18 years of age, with a 99% certainty of being at least 21, and for females they will be at least 20 years old. If at stage three then an individual of either sex will be at least 17 years of age.

The use of computed tomography (CT) to estimate age in the 2009 Victorian Bushfire Victims: A case report

The development of new imaging technologies is beginning to have an impact upon medico-legal death investigation in an increasing number of jurisdictions. Computed tomography (CT) is an imaging modality which is able to provide information to investigators without the need for a physically invasive autopsy in certain circumstances. The use of post-mortem CT as an aid to the identification of the victims of the Black Saturday bushfires is discussed with particular reference to dental age estimation. A case report is presented which demonstrates the ability of this imaging modality to separate individuals based upon dental development. Whilst CT is not yet able to adequately discriminate between differing restoration types and shapes, and therefore cannot be used for dental identification in the classic sense, the ability of this imaging modality to assess dental and skeletal development for the purpose of age estimation is valid.

The medico-legal investigation of sudden, unexpected and/or unexplained infant deaths in South Africa: where are we—and where are we going?

Sudden Infant Death Syndrome (SIDS) has been reported to be the leading cause of death in infants under 1 year of age in many countries. Unfortunately, a paucity of published research data exists in South Africa, with regard to the incidence of and investigation into the circumstances surrounding Sudden Unexplained Deaths in Infants (SUDI) and/or SIDS. Currently, even though most academic centers conform to a protocol consistent with internationally accepted standards, there exists no nationally accepted infant death investigation protocol in South Africa. It is the aim of this study to review the current practice of infant death investigation in two representative but geographically and demographically distinct centers. Retrospective case audit over a five-year period (2000-2004) was conducted at two large medico-legal mortuaries in Pretoria (Gauteng) and Tygerberg (Cape Town). Case files on all infants younger than 1 year of age were reviewed. The outcome measures included number of deaths, demographic details and the nature and final outcome of the post mortem examinations. A total of 512 cases were identified as possible SIDS cases and of these, 171 was classified as SIDS. The study showed marked inter-case and inter-divisional variation in terms of the investigation of infant deaths at the two institutions. It is envisaged that this study will focus attention on the current lack of usable data regarding sudden/unexplained/unexpected infant deaths in South Africa, and aid in the formulation and implementation of a practical (yet internationally accountable) infant death investigation protocol, which could facilitate comparisons with other countries and initiate further structured research in this field.

Natural, Unexpected Deaths: Reliability of a Presumptive Diagnosis*

We retrospectively analyzed 100 deaths because of suspicions and concerns expressed by the family. We compared the preautopsy cause of death, as determined by a thorough review of the clinical data and circumstances, to the autopsy-derived cause of death. In the majority (91/100), the preautopsy and postautopsy proximate causes of death were in agreement. In 9%, the autopsy provided information that resulted in a proximate cause of death different than anticipated. In four instances, the manner of death also was incorrect and was determined to be an accident rather than the originally presumed natural. No homicide or suicide would have been misclassified. In another nine instances, where the premortem and postmortem proximate causes of death were in agreement, the autopsy provided a specific mechanism of death. With a quality initial medicolegal death investigation, a subset of sudden deaths in adults may be reliably certified without an autopsy.

Elevated Body Core Temperature in Medico-Legal Investigation of Violent Death

Pathologically elevated body core temperature, measured at the death scene, is an important finding in medico-legal investigation of violent deaths. An abnormally high rectal temperature at any death scene may point to an underlying pathology, the influence of certain drugs or a hidden cerebral traumatism, and death by suffocation which would remain undetected without further medico-legal investigations. Furthermore, hyperthermia and fever, if unrecognized, may result in an erroneous forensic estimation of time since death in the early postmortem period by the "Henssge method." By a retrospective study of 744 cases, the authors demonstrate that hyperthermia is a finding with an incidence of 10% of all cases of violent death. The main causes are: influence of drugs, malignant tumors, cerebral hypoxia as a result of suffocation, infections, and systemic inflammatory disorders. As a consequence it must be stated, that hyperthermia must be excluded in every medico-legal death scene investigation by a correct measurement of body core temperature and a comparison between the cooling rate of the body and the behavior of early postmortem changes, notably livor and rigor mortis.

Medical Homicide and Extreme Negligence

Deaths that occur during medical care for the treatment of a disease are rarely certified as homicides. Some "medical" deaths, however, have been criminally prosecuted for manslaughter, reckless endangerment, or reckless homicide. We describe 5 deaths due to medical complications that underwent criminal prosecution. Three of the deaths were certified as homicides. Deaths certified as homicides due to the actions (or inactions) of a caregiver occur in 3 circumstances. The first is when the medical caregiver intentionally causes the death of the patient. The second is a death due to treatment by an unlicensed fraud or quack. The final circumstance is due to extreme medical negligence that involves a gross and wanton disregard for the well-being of the patient and is the most controversial in the medical community. The law defines reckless endangerment as the conscious disregard of a known substantial likelihood of injury to the patient. Criminal neglect typically is defined as the failure to provide timely, safe, adequate, and appropriate services, treatment, and/or care to a patient. In instances of extreme medical negligence, a homicide manner of death is appropriate because the fatality is due to the criminal acts (or inactions) of another. It also furthers one of the major goals of the medicolegal death investigation system, which is to safeguard the public health.

Medical Terminology Coding Systems and Medicolegal Death Investigation Data: Searching for a Standardized Method of Electronic Coding at a Statewide Medical Examiner’s Office*

Medical examiner and coroner reports are a rich source of data for epidemiologic research. To maximize the utility of this information, medicolegal death investigation data need to be electronically coded. In order to determine the best option for coding, we evaluated four different options (Current Procedural Terminology [CPT], International Classification of Disease [ICD] coding, Systematized Nomenclature of Medicine Clinical Terms [SNOMED CT], and an in-house system), then conducted internal and external needs assessments to determine which system best met the needs of a centralized, statewide medical examiner's office. Although all four systems offer distinct advantages and disadvantages, SNOMED CT is the most accurate for coding pathologic diagnoses, with ICD-10 the best option for classifying the cause of death. For New Mexico's Office of the Medical Investigator, the most feasible coding option is an upgrade of an in-house coding system, followed by linkage to ICD codes for cause of death from the New Mexico Bureau of Vital Records and Health Statistics, and ideally, SNOMED classification of pathologic diagnoses.

Manufactured populations: What do contemporary reference skeletal collections represent? A comparative study using the Maxwell Museum documented collection

The extent to which archaeological or cemetery skeletal collections accurately represent the population from which they were drawn cannot be known. The creation of documented or forensic skeletal collections, derived from donation or autopsy, was intended to overcome many of the problems inherent in archaeological populations, yet it is misleading to assume such collections represent a specific or defined population. This study compares the documented skeletal collection curated at the Maxwell Museum to annual demographic information from three relevant populations: (i) the living population of New Mexico (NM), (ii) the deceased of NM, and (iii) the subset of decedents who undergo a medicolegal death investigation or autopsy. Results indicate that the Maxwell Documented collection differs significantly from all three populations in every variable examined: age, sex, ethnicity/race, cause, and manner of death. Collection development that relies on body donation or retention of unclaimed bodies under coroner/medical examiner statutes results in a biased sample, with significant overrepresentation of males, Whites, the elderly, those who die unnatural deaths and individuals with antemortem traumatic injury or surgical intervention. Equally problematic is the perception that the collection has documented race or ethnicity, when in fact only 17% was self-reported, while the affinity of the remaining individuals was determined by pathologists or other observers. Caution is warranted in how this and similar collections are used and interpreted by researchers. Although documented reference collections are useful in developing methods of estimating age or sex, they are not a proxy for modern or racially/ethnically defined populations.

Skeletal Estimation and Identification in American and East European Populations*

Forensic science is a fundamental transitional justice issue as it is imperative for providing physical evidence of crimes committed and a framework for interpreting evidence and prosecuting violations to International Humanitarian Law (IHL). The evaluation of evidence presented in IHL trials and the outcomes various rulings by such courts have in regard to the accuracy or validity of methods applied in future investigations is necessary to ensure scientific quality. Accounting for biological and statistical variation in the methods applied across populations and the ways in which such evidence is used in varying judicial systems is important because of the increasing amount of international forensic casework being done globally. Population variation or the perceived effect of such variation on the accuracy and reliability of methods is important as it may alter trial outcomes, and debates about the scientific basis for human variation are now making their way into international courtrooms. Anthropological data on population size (i.e., the minimum number of individuals in a grave), demographic structure (i.e., the age and sex distribution of victims), individual methods applied for identification, and general methods of excavation and trauma analysis have provided key evidence in cases of IHL. More generally, the question of population variation and the applicability of demographic methods for estimating individual and population variables is important for American and International casework in the face of regional population variation, immigrant populations, ethnic diversity, and secular changes. The reliability of various skeletal aging methods has been questioned in trials prosecuted by the International Criminal Tribunal for the Former Yugoslavia (ICTY) in The Prosecutor of the Tribunal against Radislav Krstic (Case No. IT-98-33, Trial Judgment) and again in the currently ongoing trial of The Prosecutor of the Tribunal against Zdravko Tolimir, Radivolje Miletic, Milan Gvero, Vinko Pandurevic, Ljubisa Beara, Vujadin Popovic, Drago Nikolic, Milorad Trbic, Ljubomir Borovcanin (IT-05-88-PT, Second Amended Indictment). Following the trial of General Krstic, a collaborative research project was developed between the Forensic Anthropology Center at The University of Tennessee (UT) and the United Nations, International Criminal Tribunal for the Former Yugoslavia, Office of the Prosecutor (ICTY). The purpose of that collaboration was to investigate methods used for the demographic analysis of forensic evidence and where appropriate to recalibrate methods for individual estimation of age, sex, and stature for specific use in the regions of the former Yugoslavia. The question of "local standards" and challenges to the reliability of current anthropological methods for biological profiling in international trials of IHL, as well as the performance of such methods to meet the evidentiary standards used by international tribunals is investigated. Anthropological methods for estimating demographic parameters are reviewed. An overview of the ICTY-UT collaboration for research aimed at addressing specific legal issues is discussed and sample reliability for Balkan aging research is tested. The methods currently used throughout the Balkans are discussed and estimated demographic parameters obtained through medico-legal death investigations are compared with identified cases. Based on this investigation, recommendations for improving international protocols for evidence collection, presentation, and research are outlined.

A tale of two cities: a review of homicide in Melbourne and Glasgow in 2005

The Departments of Forensic Medicine and Science at the University of Glasgow and the Victorian Institute of Forensic Medicine in Melbourne are academic university-based forensic medicine units providing a medico-legal death investigation service to the Strathclyde region of Scotland and the State of Victoria, Australia, respectively. We reviewed and compared homicides in the two jurisdictions for the year 2005. Whilst gross numbers were comparable, the homicide rate per capita was significantly higher in Glasgow. Death due to stabbing comprised a greater proportion of homicides in Glasgow, reflective of a well recognised social epidemic of knife-related trauma amongst young males. Blunt force trauma was the most prevalent cause of homicidal injury in the Australian cases. The cities shared a low incidence of firearm- related homicide, reflective of strict legislative initiatives.

Animal-Caused Fatalities in New Mexico, 1993–2004

To evaluate animal-caused fatalities in New Mexico using data collected during medicolegal death investigations, including toxicology, survival interval, and circumstances. A retrospective review of the computerized database and hard copies of files from a centralized, statewide medical examiner's office, excluding deaths due to zoonotic diseases and motor vehicle collisions involving animals. Between 1993 and 2004, 63 deaths caused by animals were reported in New Mexico. The majority of decedents were male (46/63, 73%) and non-Hispanic white (33/63, 52%). Horses were the most commonly implicated animals, with 43 (68%) deaths due to a person being thrown from, crushed, dragged, or kicked by a horse. Cattle caused 9 deaths (14%), dogs caused 3 (5%), and venomous animals caused 3, whereas a bear was responsible for 1 death. Ten decedents (16%) had alcohol present at the time of death, and 8 would have been over the legal blood alcohol concentration for driving (0.08%). Ten deaths (16%) were work-related and included deaths of jockeys and ranch workers. The majority of deaths (42/63, 67%) occurred in remote locations, potentially delaying access to treatment. Survival intervals ranged from 1 day to 33 years. Whereas both human and animal behavior can be difficult to predict, a review of animal-caused fatalities investigated by a medical examiner revealed that in many cases, deaths could have been prevented by either the use of protective gear or alterations in human behavior.

Adrenal lipomas: Incidental autopsy findings

Two rare cases of lipomas of the adrenal gland are reported. In both cases the tumor was found incidentally at autopsy, in the course of the medicolegal investigation of death. The first case involved a small tumor of the left adrenal gland in a 70-year-old man who died by drowning. In the second case, a previously healthy 45-year-old man died suddenly. At autopsy a lipoma of the right adrenal gland was associated with a pheochromocytoma in the contralateral gland.

A Functional Approach to Sudden Unexplained Infant Deaths

There is a great deal of variation in the methods and wording used by medical examiners in the medicolegal investigation and certification of infant deaths. This paper was created by the NAME Ad Hoc Committee on Sudden Unexplained Infant Death to address several specific issues, namely: * To establish a functional approach to the investigation of sudden unexplained infant deaths; * To outline a "bare minimum" set of recommendations to define the scope of investigation required; * To recommend methods and wording to be used when certifying infant deaths; * To develop a list of potential stressors or possible external causes of death that should be identified and reported on the death certificate and/or within a medical examiner/coroner office database. This paper was electronically posted for NAME member review and comment for a period of 30 days. The paper was further revised based on member comments and then submitted to the NAME board of directors in the fall of 2005 prior to the annual meeting. This text of this paper was officially approved and endorsed by the NAME board of directors on October 14, 2005, at the annual meeting in Los Angeles, CA.

National Association of Medical Examiners Position Paper on the Medical Examiner Release of Organs and Tissues for Transplantation

The medical examiner community plays a key role in the organ and tissue procurement process for transplantation. Since many, if not most, potential organ or tissue donors fall under medicolegal jurisdiction, the medical examiner bears responsibility to authorize or deny the procurement of organs or tissues on a case-by-case basis. This responsibility engenders a basic dichotomy for the medical examiner's decision-making process. In cases falling under his/her jurisdiction, the medical examiner must balance the medicolegal responsibility centered on the decedent with the societal responsibility to respect the wishes of the decedent and/or next of kin to help living patients. Much has been written on this complex issue in both the forensic pathology and the transplantation literature. Several studies and surveys of medical examiner practices, as well as suggested protocols for handling certain types of cases, are available for reference when concerns arise that procurement may potentially hinder medicolegal death investigation. It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings. The purpose of this position paper is to review the available data, the arguments for and against medical examiner release, and to encourage the release of organs and tissues in all but the rarest of circumstances.

Independence Day Explosion on Lovers Key*

The display of fireworks is a popular holiday celebration in the United States. Because injuries due to recreational fireworks-related explosions among private consumers are relatively common, the sale of fireworks is regulated by the federal government and is also limited by state and local laws. In contrast, because fireworks display companies are under tight safety regulations, explosions in the professional pyrotechnics industry are uncommon occurrences, and the literature contains rare reports of injuries and fatalities resulting from such explosions. We report the 2003 Fourth of July commercial fireworks explosion on Lovers Key in southwest Florida that resulted in five fatalities. Events occurring during the investigation of the scene of this explosion illustrate the unique considerations and hazards for medicolegal death investigators, law enforcement and other investigative agencies. Additionally, this case demonstrates unusual aspects of the postmortem examinations performed on victims of fireworks-related incidents.

Review of: Spitz and Fisher's Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation, 4th Edition

Review of: <i>Spitz and Fisher's Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation, 4th Edition</i>

Hypothermia and Hyperthermia Medicolegal Investigation of Morbidity and Mortality From Exposure to Environmental Temperature Extremes

The determination of the cause of death from exposure to extreme temperatures is a diagnosis of exclusion. Because both clinical and autopsy findings are nonspecific, a thorough investigation of the background and scene, evaluation of temporally relevant environmental conditions, and assessment of the victim's underlying state of health with appropriate laboratory studies, which frequently include autopsy, are essential to establish the cause of injury and/or death with reasonable medical probability. Individuals may encounter environmental extremes in many settings during any season. Both constitutional and external factors exacerbate the stress brought about by extreme temperature. This article reviews guidelines for forensic investigation into environmental temperature extremes that contribute to an important seasonal grouping of morbidity and mortality in the United States. Articles on clinical and pathologic aspects of hyperthermia and hypothermia were collected and reviewed. Recognition of multiple risk factors predisposing humans to both cold-related and heat-related morbidity and mortality enhances prevention. Awareness of the susceptibility of these exposed at-risk individuals is crucial to investigations by both clinicians and medicolegal death investigators.