Medicolegal Death Investigation Research Articles

Strategic Decision-Making by a Forensic Toxicology Laboratory in Response to an Emerging NPS: Detection, Quantitation and Interpretation of Carfentanil in Death Investigations in Ontario, Canada, July 2017 to June 2018.

The proliferation of novel psychoactive substances (NPS) and the current opioid epidemic creates challenges for a toxicology laboratory. Methods capable of detecting and quantitating emerging compounds must be established despite limited information on toxicologically relevant concentrations. This paper will (i) describe how a publicly funded forensic laboratory reacted to the emergence of carfentanil as a public safety concern and (ii) contribute to the existing forensic literature by presenting a series of deaths involving carfentanil between July 2017 and June 2018. The Centre of Forensic Sciences is the primary provider of forensic toxicology testing in medicolegal death investigations in the province of Ontario. When carfentanil was first identified in the illicit drug supply, routine screening methods used by this laboratory were not sufficiently sensitive to detect the drug at concentrations expected in blood samples. Previously validated, multi-target liquid chromatography-tandem mass spectrometry (LC-MS-MS) quantitative methods already in use by the laboratory did show improved detectability for carfentanil. Thus, an existing LC-MS-MS method was adapted to include carfentanil, achieving improved sensitivity while also providing quantitation in suspected drug-related deaths. This approach had the added benefit that the LC-MS-MS method selected for modification was used in all death investigations requiring toxicology analysis in Ontario, thereby providing an opportunity for surveillance. Using this method, 4,953 cases were analyzed with carfentanil detected at a concentration greater than the limit of detection (0.05 ng/mL) in 160 decedents. Postmortem blood carfentanil concentrations ranged from less than 0.1 to 9.2 ng/mL. Of the 160 carfentanil-positive cases, 156 were classified as either mixed drug toxicity or carfentanil overdose. The approach described enabled this laboratory to efficiently implement a quantitative test for carfentanil in all death investigations, providing a useful template for modifying existing methods when a new psychoactive substance becomes available in the population.

Review of: Spitz and Fisher’s medicolegal investigation of death: Guidelines for the application of pathology to crime investigation, 5th Edition

Review of: Spitz and Fisher’s medicolegal investigation of death: Guidelines for the application of pathology to crime investigation, 5th Edition

Legal Frameworks: A Starting Point for Strengthening Medicolegal Death Investigation Systems and Improving Cause and Manner of Death Statistics in Civil Registration and Vital Statistics Systems.

Medicolegal death investigation systems, which generally fall within one of three types-medical examiner, coroner, or law-enforcement-led systems-investigate deaths that are unnatural or suspicious. The current quality of cause of death statistics on deaths investigated within medicolegal death investigation systems globally limits effective public health response. A starting point to strengthening global medicolegal death investigation systems and improving the quality of cause and manner of death reported to civil registration systems is through a strong legal framework. Two resources, the United Nations Statistics Division Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management and the Global Health Advocacy Incubator Legal and Regulatory Toolkit for Civil Registration, Vital Statistics and Identity Management, present recommendations and provide guidance to country stakeholders in reviewing and revising their medicolegal death investigation legal frameworks. Physician determination of cause and manner of death, defined criteria for case referral to the medicolegal death investigation system, an amendment process, and investigation collaboration are four core considerations for medicolegal death investigation system legal frameworks. A strong medicolegal death investigation legal framework is a necessary starting point, but it is not sufficient for ensuring the timely, accurate, and complete reporting of cause and manner of death in national vital statistics.

Five-year overview of fatal thermal and electrical burns in Johannesburg, South Africa

Thermal and electrical burn injuries affect millions of people globally each year. South Africa is a developing country where fatal fires are common. Despite the pervasiveness of fatal thermal and electrical burns in South Africa, there is a paucity of information regarding the frequency of such fatal burns in the City of Johannesburg. We aimed to describe the demographics and frequency of fatal thermal and electrical burn cases received at the Johannesburg Forensic Pathology Services Medico-Legal Mortuary for medico-legal death investigations, and compare the burn mortality rates between Johannesburg and those reported in Cape Town, Pretoria, and Mpumalanga. This study was a 5-year (2010–2014) retrospective review of 185 forensic medico-legal case files of fatal burns (156 thermal burn cases and 29 electrical burn cases) received at the Johannesburg Forensic Pathology Services Medico-Legal Laboratory. The demographics at the greatest risk of fatal burns in Johannesburg, South Africa are black (2.11 per 100 000) and male (1.03 per 100 000) individuals, and those in the 30–39-year age group (3.6 per 100 000). Children aged 0–9 years had a high mortality rate due to thermal burns (3.44 per 100 000). The most common type of fatal burns is thermal in nature, as a result of flames (1.62 per 100 000). Electrical burns are relatively rare (0.3 per 100 000). Burns are prevalent in the winter months, most notably in August. Burn wounds are common on the head, chest, back, and abdomen. Johannesburg has an overall lower burn mortality rate and incidence frequency than Cape Town, Pretoria, and Mpumalanga. This study is the first to report on fatal burns in Johannesburg, South Africa.Significance:
 
 A description is provided of fatal thermal and electrical burns of individuals whose deaths were investigated at the Johannesburg Forensic Pathology Services Medico-Legal Mortuary.
 The results highlight the demographic groups at risk of fatal burns in Johannesburg, South Africa.
 Johannesburg has a lower fatal burn incidence and mortality rate than Cape Town, Pretoria, and Mpumalanga; however, young people, particularly male individuals, are at greatest risk.

Fatal and Nonfatal Injury Patterns of Stranded Motorists.

Because nonfatal and fatal incidents for stranded motorists are not separated from vehicular accidents, little data are available on incident characteristics. To close this gap, data fields were inserted into databases at a medical examiner's office and two trauma centers to collect injury-related information. Forensic nurses and pathologists aided in forming a collaboration among the agencies involved and supported data collection efforts. Data collected over a 5-year period were examined for injury patterns to determine risk factors affecting these patterns. Of the total sample (N = 219), 24.7% had spinal injuries resulting in fatal injuries for 46 of 54 individuals. The odds were stranded motorists with spine-related injuries (C1-C7) had 9.13 times higher risk for a fatal outcome compared with those without spine-related injuries. Severe injuries (Abbreviated Injury Scale scores ≥ 4) noted for head/neck (29.7%) and chest (24.2%) were significantly associated with fatality. Of the 219 cases, 22.8% were inside of a stopped vehicle, and 77.2% were outside a vehicle at the time of injury. Outcomes illustrated the success of the interprofessional collaboration between trauma centers and a medicolegal death investigation agency that resulted in data useful for forensic nurses and pathologists documenting evidence, emergency and trauma responding personnel in patient priority stabilization, and injury prevention specialists for highway safety programs.

Comparison of Accumulated Degree-Days and Entomological Approaches in Post Mortem Interval Estimation

Simple SummaryAmong the investigative questions to define the temporal frame of a criminal event, the time since death plays a fundamental role. After death, the body goes through a series of physical and chemical transformations—known as decomposition. The way in which different parts of the body undergo these transformations can be quantified with a scale of scores (TBS, the total body score) and used for the time since death evaluation using the accumulated degree-days (ADDs) parameter, which accounts for time and temperature. This method is reported as TBS/ADD. Another way to estimate the time since death is based on the insect development on the body. Flies represent the first body coloniser and the development of their immature stages is used to define the time of colonisation that is temperature dependent and species specific. In this study, the two methods were compared based on 30 forensic cases occurring in northern Italy. The results highlighted the limits of the TBS/ADD method and the importance of the entomological approach, keeping in mind that with insects the colonization time is evaluated. This time is the minimum time since death.Establishing the post mortem interval (PMI) is a key component of every medicolegal death investigation. Several methods based on different approaches have been suggested to perform this estimation. Among them, two methods based their evaluation on the effect of the temperature and time on the considered parameters: total body score (TBS)/accumulated degree-days (ADDs) and insect development. In this work, the two methods were compared using the results of minPMI and PMI estimates of 30 forensic cases occurring in northern Italy. Species in the family Calliphoridae (Lucilia sericata, Calliphora vomitoria and Chrysomya albiceps) were considered in the analyses. The results highlighted the limits of the TBS/ADD method and the importance of the entomological approach, keeping in mind that the minPMI is evaluated. Due to the fact that the majority of the cases occurred in indoor conditions, further research must also be conducted on the different taxa to verify the possibility of increasing the accuracy of the minPIM estimation based on the entomological approach.

Postmortem radiologic and pathologic findings in COVID-19: The Toronto experience with pre-hospitalization deaths in the community

Over a year after the initial emergence of the disease, the COVID-19 pandemic continues to strain healthcare systems worldwide. The value of feedback and connection between clinical care, public health, and death investigation systems has never been more clear. To this end, knowledge of the radiologic and histopathologic features of fatal COVID-19 is critical for those working with the living and the dead. Most of the medical descriptions of COVID-19 are either focused on clinical in vivo medical imaging or autopsies performed following an intensive course of treatment over days to weeks prior to death, rather than deaths in the community prior to hospitalization. Here we report the postmortem computed tomography (PMCT) and lung histopathology in five fatal cases of COVID-19 that were subject to medicolegal death investigation. All individuals died in the community without medical treatment, or after a brief terminal admission to hospital. In these cases, the main PMCT findings included: diffuse lung changes including ground glass-type opacifications, a “crazy paving” appearance, variable areas of more dense consolidation, and relatively few areas of spared/less involved lung parenchyma. The unifying histopathology was diffuse alveolar damage in various stages of cellular evolution. In all cases, the pattern of PMCT and the lung histopathology corroborated the diagnosis of COVID-19. We propose the routine use of PMCT as a potential screening tool for the identification of COVID-19 related fatalities in the medicolegal setting where a paucity of historical information may not otherwise permit the identification of this disease prior to autopsy.

Patterns of Intentional Dismemberment in Florida Medicolegal Death Investigations

This study identifies broad patterns of intentional dismemberment in Florida as observed in cases accessioned over a 15-year period at the University of Florida C. A. Pound Human Identification Laboratory. A review of all case files dating from July 2003 through June 2018 (N = 959) found 28 individuals with indications of intentional dismemberment. Decedents ranged from neonatal to 76 years in age at death; half were female, and 91.7% were identified by the medical examiner as White. Transection via sawing was the most common dismemberment mode (50%), followed by disarticulation of joints (19%). The most common implement was a saw, and electric reciprocating saws were the most common saw type. These data are compared to multiple U.S.-based dismemberment samples, positioned within a larger U.S. framework, and assessed against international data. Combined U.S. data suggest female homicide victims are more likely to be dismembered than male homicide victims. The use of three different modes of dismemberment, with transection by sawing more common than transection by chopping and transection by any means more common than disarticulation, is noted across the Eastern U.S. However, selection of implement and mode may be influenced by sub-regional factors such as population density. This is in contrast to available Latin American data, which indicate dismemberments—commonly in the context of organized violence and used as a means of symbolic communication—occur primarily to males and overwhelmingly by chopping. The discrepancies in dismemberment patterns between the U.S. and Latin American contexts illustrate the importance of sociopolitical circumstance when making broad comparisons across geographic samples.

Bringing the science back into forensic science in death investigations in the Philippines during the COVID-19 pandemic

Abstract After a pandemic-filled 2020 had finally come to an end, many were looking forward to a new year filled with renewed hope and fresh beginnings. Unfortunately for a 23-year old Filipina, the first day of the year would turn out to be her last day on earth. While a single individual's death on New Year's day would typically not be a newsworthy event in the Philippines, this particular case sparked a media frenzy. It exposed the flaws of a death investigation system still reeling from the many unsolved cases of extrajudicial killings brought about by the war on drugs [9] . To date, the Philippines does not have an independent, science-based medico-legal death investigation system (Go, 2021; Pastor, 2021). This commentary aims to provide a case narrative to highlight the urgency of adopting a systematic death investigation system, seek justice for the victim's family, reduce the possibilities of wrongful accusations and convictions, and maximize the use of limited and costly forensic resources in the Philippines.

Concentrations of para-Fluorofuranylfentanyl in Paired Central and Peripheral Blood Collected during Postmortem Death Investigations.

The opioid epidemic in the USA has been associated with an increasing mortality rate in large part due to the emergence and proliferation of synthetic opioids over the last 15 years. Fentanyl and its analogs have played a large part in these statistics due to their potency and toxicity. Fluorofuranylfentanyl (FFF) is a fentanyl analog that emerged in the USA in 2018 and was associated with numerous adverse events and deaths. During this study, a liquid chromatography tandem mass spectrometry workflow was developed to accurately identify the isomer of FFF present (ortho- vs. meta- vs. para-) in medicolegal death investigation cases from Pinellas County, Florida. FFF was quantified in central and peripheral blood samples collected at autopsy. In addition, the metabolism of FFF was studied using liquid chromatography quadrupole time-of-flight mass spectrometry. para-FFF was quantitatively confirmed in 29 postmortem cases; no other isomer of FFF was detected. Central blood concentrations ranged between 0.66 and 73 ng/mL (mean = 11 ± 14 ng/mL, median = 10 ng/mL) and peripheral blood concentrations ranged between 0.53 and 23 ng/mL (mean = 5.7 ± 6.4 ng/mL, median = 2.7 ng/mL). A comparison of central to peripheral blood concentrations was evaluated to determine the possibility of postmortem redistribution. The metabolism of ortho-FFF was studied and found to undergo metabolic processes similar to fentanyl, producing ortho-fluorofuranyl-norfentanyl, fluoro-4-anilino-N-phenethylpiperidine, and hydroxylated species. The results of this study demonstrate the toxicity of FFF and its implication in medicolegal death investigations. Laboratories must remain aware of new or re-emerging fentanyl analogs, as they pose significant risks to public health and public safety.

Workplace safety concerns in medico-legal death investigations related to COVID-19.

The personnel involved in the management of COVID-19 affected dead bodies, including law enforcement personnel at the scene of crime, personnel involved in transportation of the dead bodies, forensic practitioners, autopsy pathologists, mortuary personnel, as well as the family members of the dead, etc. are at risk of exposure to SARS-CoV-2 infection. Post-mortem examination is a high-risk procedure, considering that it involves aerosol generating procedures, and exposure to body fluids. The safety of the forensic practitioners and support staff in the management of suspected or confirmed COVID-19 deaths hence, is of extreme importance, especially in the absence of pre-autopsy testing for COVID-19 and due to non-availability of adequate first-hand medical history of the deceased. This communication aims to highlight the current practices and advises certain guidelines in ensuring occupational health and safety in view of these risks in medico-legal death investigations.

Fatal self-injury in the United States, 1999-2018: Unmasking a national mental health crisis.

BackgroundSuicides by any method, plus ‘nonsuicide’ fatalities from drug self-intoxication (estimated from selected forensically undetermined and ‘accidental’ deaths), together represent self-injury mortality (SIM)—fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999–2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification.MethodsFor this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the ‘nonsuicide’ SIM component.FindingsThe national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population—the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of ‘nonsuicide’ drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05).InterpretationDepiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice.FundingThis study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412–01; 1R21DA046521-01A1).

Prevalence of SARS-CoV-2 Antibodies in First Responders and Public Safety Personnel, New York City, New York, USA, May-July 2020.

We conducted a serologic survey in public service agencies in New York City, New York, USA, during May–July 2020 to determine prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among first responders. Of 22,647 participants, 22.5% tested positive for SARS-CoV-2–specific antibodies. Seroprevalence for police and firefighters was similar to overall seroprevalence; seroprevalence was highest in correctional staff (39.2%) and emergency medical technicians (38.3%) and lowest in laboratory technicians (10.1%) and medicolegal death investigators (10.8%). Adjusted analyses demonstrated association between seropositivity and exposure to SARS-CoV-2–positive household members (adjusted odds ratio [aOR] 3.52 [95% CI 3.19–3.87]), non-Hispanic Black race or ethnicity (aOR 1.50 [95% CI 1.33–1.68]), and severe obesity (aOR 1.31 [95% CI 1.05–1.65]). Consistent glove use (aOR 1.19 [95% CI 1.06–1.33]) increased likelihood of seropositivity; use of other personal protective equipment had no association. Infection control measures, including vaccination, should be prioritized for frontline workers.

Werner U Spitz and Francisco J Diaz (eds), Spitz and Fisher’s medicolegal investigation of death

Werner U Spitz and Francisco J Diaz (eds), <i>Spitz and Fisher’s medicolegal investigation of death</i>

Werner U Spitz and Russell S Fisher, Medico-legal investigation of death: Guidelines for the application of pathology to crime investigation

Werner U Spitz and Russell S Fisher, <i>Medico-legal investigation of death: Guidelines for the application of pathology to crime investigation</i>

Examining the Examiners: How Medical Death Investigators Describe Suicidal, Homicidal, and Accidental Death

ABSTRACT This study describes differences in medicolegal death investigators’ written descriptions for people who died by homicide, suicide, or accident. We evaluated 17 years of death descriptions from a midsized metropolitan midwestern county in the United States to assess how death investigators psychologically respond to different manners of death (N = 10,408 cases). Automated text analyses suggest investigators describe accidental deaths with more immediacy relative to homicides, while they also described suicidal deaths in less emotional terms than homicides as well. These data suggest medicolegal death investigators have different psychological reactions to circumstances and manners of death as indicated by their professional writing. Future research may surface context-specific psychological reactions to vicarious trauma that could inform the design or personalization of workplace-coping interventions.

Analysis of the Illicit Opioid U-48800 and Related Compounds by LC–MS-MS and Case Series of Fatalities Involving U-48800

We report a method for the detection and quantitation of 12 drugs and 2 metabolites in the same structural class as the illicit mu-opioid agonist U-47700 in human whole blood. These substances are either known or suspected to be present as potential novel opioids in illicit drug markets. The general class of these drugs was developed in pharmaceutical research programs in the 1970s, but these drugs have recently become of concern for overdoses and death in opioid users in the USA and internationally. The scope of analysis included the following compounds: methylenedioxy U-47700, ethylenedioxy U-47700, ethylenedioxy U-51754, U-69593, U-47931E (bromadoline), U-47700, U-48800, U-49900, U-51754, U-50488, propyl U-47700 and isopropyl U-47700. Additionally, two metabolites N,N-didesmethyl U-47700 and desmethyl U-47700 were also included in the scope. Drugs were extracted from human whole blood using solid-phase extraction, and the extracts were analyzed by liquid chromatography--tandem mass spectrometry. The assay was validated with respect to bias, carryover, interference, within-run and between-run precision, and accuracy. Eight medicolegal death investigation cases that had screened positive for U-48800 by liquid chromatography--time-of-flight mass spectrometry were successfully confirmed and quantified using this method. The mean and median concentrations of U-48800 in these cases were 2.5 (±2.1) and 1.8 ng/mL, respectively, with a range of concentrations of 0.27-6.2 ng/mL. Case history information including the presence of other drugs in combination are described and discussed.

Human identification: a review of methods employed within an Australian coronial death investigation system.

Whilst many identification methods have been widely described and discussed in the literature, and considered in disaster and humanitarian contexts, there has been limited reporting and evaluation of the identification methods used in domestic medico-legal death investigation contexts. The aim of this study was to evaluate the identification methods utilised at the Victorian Institute of Forensic Medicine (VIFM), which forms part of a coronial medico-legal death investigation system. The method of identification and time taken to complete the identification were reviewed for all cases admitted to the VIFM over a five-year period from 1 July 2015 to 30 June 2020. The majority, 91%, of individuals admitted to the VIFM were visually identified. The remaining 9% of cases required identification by primary methods (i.e. fingerprints, DNA or dental) or, when those methods were not possible, by secondary methods (i.e. circumstantial). Visual identifications were the timeliest, taking an average of 1.5days, whilst primary identification methods required an average of 5days to complete. The triaging of identification methods, dependent on the case context, body preservation, availability of ante-mortem data, legal requirements and admissibility of the method, are determined by identification coordinators within the Human Identification Service (HIS) to ensure the most appropriate and timely method is employed. This review of human identification methods provides the foundation for future analyses to compare workflow processes and improve identification methods utilised in domestic medico-legal contexts.

Quality Assurance Through Standard Operating Procedures Development and Deviation: A Medicolegal Death Investigation Systems Response to the COVID-19 Pandemic.

ABSTRACTStandard operating procedures drive everyday practice within any organization, including those within a forensic setting. In the event of unusual circumstances, organizations must respond rapidly to address the impact on operations while ensuring that the quality and safety outcomes of routine services are not affected. This case study illustrates how standard operating procedures can be newly developed or modified, and rapidly deployed and quickly revised, to address unusual circumstances. The response to the COVID-19 pandemic is used as an example in this case report.

Nurses and Medicolegal Death Investigation.

Forensic nurses currently serve in medicolegal death investigation settings nationwide, yet registered nurses seldom recognize death investigation as a career option. The purpose of this article is to describe medicolegal death investigation in the United States and the roles nurses can achieve, depending upon state and agency job requirements. Duties and qualifications for job positions, whether filled by election, appointment, or staff hiring, are described to provide examples of nurses' roles within the medicolegal death investigation setting and to present career options. Forensic nurses have the educational preparation, medical skills, and forensic knowledge to serve within death investigation systems as a chief officer (e.g., coroner), deputy officer, or staff investigator.