Medicolegal Death Investigation System Research Articles

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

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

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

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

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

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

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

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

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

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

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

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

Medico-Legal Death Investigation Systems – Poland

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

Medico-Legal Death Investigation Systems – New Zealand

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

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

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

Coroner county systems are associated with a higher likelihood of unclassified drug overdoses compared to medical examiner county systems

ABSTRACT Background: There is a striking geographic variation in drug overdose deaths without a specific drug recorded, many of which likely involve opioids. Knowledge of the reasons underlying this variation is limited. Objectives: We sought to understand the role of medicolegal death investigation (MDI) systems in unclassified drug overdose mortality. Methods: This is an observational study of 2014 and 2018 fatal drug overdoses and U.S. county-level MDI system type (coroner vs medical examiner). Mortality data are from the CDC’s National Center for Health Statistics. We estimated multivariable logistic regressions to quantify associations between MDI system type and several outcome variables: whether the drug overdose was unclassified and whether involvement of any opioid, synthetic opioid, methadone, and heroin was recorded (vs unclassified), for 2014 (N = 46,996) and 2018 (N = 67,359). Results: In 2018, drug overdose deaths occurring in coroner counties were almost four times more likely to be unclassified (OR 3.87, 95% CI 2.32, 6.46) compared to medical examiner counties. These odds ratios are twice as large as in 2014 (difference statistically significant, P < .001), indicating that medical examiner counties are improving identification of opioids in drug overdoses faster than coroner counties. Conclusions: Accurate reporting of drug overdose deaths depends on MDI systems. When developing state policies and local interventions aimed to decrease opioid overdose mortality, decision-makers should understand the role their MDI system is playing in underestimating the extent of the opioid overdose crisis. Improvements to state and county MDI systems are desirable if accurate reporting and appropriate policy response are to be achieved.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States

Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (β = 4.362), labor underutilization rate (β = 0.728), manufacturing employment (β = -0.056), homelessness rate (β = -0.125), percentage nonreligious (β = 0.041), non-Hispanic White race and ethnicity (β = 0.087), prescribed opioids for 30 days or more (β = 0.117), and percentage without health insurance (β = -0.013) and 5 factors associated with the suicide rate: percentage male (β = 1.046), military veteran (β = 0.747), rural (β = 0.031), firearm ownership (β = 0.030), and pain reliever misuse (β = 1.131). These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Caseloads in forensic anthropology

AbstractObjectivesThere are currently no baseline data regarding the amount and types of case reports produced by forensic anthropologists. This research fills that gap by providing data on caseloads of practicing forensic anthropologists and identifying variables that may contribute to amount and type of casework.Materials and methodsA survey was distributed to practicing forensic anthropologists (n = 364) to explore number of case reports written and possible influential factors. Questions included demographic information, employment type, institution where master's degree or PhD were obtained, type of reports written, professional organization membership, certification, graduate research focus, among others. Data were analyzed using summary statistics, a random forest model, network analysis, and structural equation modeling.ResultsThe mean number of sole‐authored skeletal analysis reports per year was 12.33 and field recovery reports was 2 per year. Statistical analyses identified several variables influencing case loads which included: number of fieldwork reports per year, current employment, total number of cases analyzed, age, publication record, and institution of doctoral degree. Network analyses revealed that individuals in academic settings tended to have a bioarchaeological research focus from their graduate work, whereas those in an applied setting had a focus on forensic anthropology. Further, degree institution influenced employment type.Discussion/conclusionsThese data address expectations for the number of cases analyzed by a forensic anthropologist per year and set a baseline for expectations and performance. Based on these results, we suggest that forensic anthropology is underutilized in the medicolegal death investigation system and more forensic anthropologists should be employed within Medical Examiner/Coroner's Offices.

The Anatomy of a Medico-Legal System. Medical Practitioners and the Investigation of Suspicious Deaths in Early Modern Flanders

During the early modern period, medical practitioners came to play an increasingly important role in criminal proceedings throughout continental Europe. Nevertheless, medico-legal procedures in the Southern or Habsburg Netherlands have hardly received any attention from historians of forensic medicine. The present article aims to address this issue by studying how suspicious deaths were investigated in the early modern County of Flanders. More specifically, three major aspects of the Flemish medico-legal death investigation system are analysed: the composition of the corps of medical practitioners on which the judicial authorities relied to conduct post-mortem examinations, the content of post-mortem reports, and arrangements for the remuneration of medical experts. Although surgeons initially constituted the principal group of medical examiners, university-trained physicians were increasingly required to participate in death investigations over the course of the seventeenth and eighteenth centuries. Furthermore, this period also witnessed a gradual increase in the number of internal autopsies. However, arrangements for the payment of medical experts remained largely unchanged throughout the early modern period.

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.

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.

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.

The role of the forensic anthropologist in the pediatric autopsy: Interpretations, contributions, and challenges

AbstractChild maltreatment is a growing medicolegal and social concern and forensic anthropologists in the United States are more frequently being asked to participate in pediatric autopsies to evaluate skeletal injuries. These injuries may be occult to medical imaging and the autopsy itself, but the forensic anthropologist directly evaluates the skeletal tissue which can dramatically improve the sensitivity and specificity of the analysis. The training and methods of forensic anthropologists provide them with the unique perspective of comprehending the anatomical, biomechanical, and physiological properties of human pediatric bone which informs their interpretations of time since injury and mechanism of trauma. This perspective also permits the ability to differentiate between growth and development, skeletal anomalies/variants, and traumatized bone which can be of distinct consequence to the forensic pathologist's cause and manner of death determination. This review is intended for forensic anthropologists and others in the medicolegal community who are tasked with identifying and interpreting pediatric skeletal trauma. The research and scholarly work cited herein is the most current bibliography for comprehending the role and contribution(s) of the forensic anthropologist in the pediatric autopsy, the techniques and methods available to them, and the challenges and cautions associated with this delicate work.This article is categorized under: Forensic Anthropology &gt; Trauma Analysis Forensic Medicine &gt; Imaging Modalities Forensic Medicine &gt; Medicolegal Death Investigation Systems

Proposal of the Autopsy Guideline for Infectious Diseases: Preparation for the Post-COVID-19 Era

With the rapidly spreading coronavirus disease 2019 (COVID-19) pandemic over the past few months, the world is facing an unprecedented crisis. Innumerable lives have been lost to this novel infectious disease, the nature of which supersedes conventional medical understanding. People around the world are sacrificing their daily lives and enduring the crisis regardless of national boundaries and cultural backgrounds. The COVID-19 pandemic is not just a global health crisis, several aspects of life in the post-COVID-19 era are also being contemplated. Experts in unison are warning that the upcoming changes in all areas of life could potentially be far more drastic than ever experienced in the entire human civilization. The medical community is no exception, and therefore, personnel involved in forensic medicine also need to be adequately prepared for the future. Forensic medicine is a branch of medicine dedicated to one of the most important stages of the human lifecycle and has always been at the forefront in times of unprecedented social change. We present new autopsy guidelines in forensic medicine, formulated based on the various infectious diseases that we presently live with and may encounter in the future. In formulation of these guidelines several considerations have been taken into account, namely, the role forensic pathologists should play in the post-COVID-19 era and the necessary preparations as well as the support needed from society to fulfill that role. The present COVID-19 outbreak should be a starting point for formulating improvements in current practices in forensic science, including autopsy biosafety practices and the medicolegal death investigation system. Key Words: Autopsy · Infectious disease · Guideline · COVID-19 · Forensic medicine

Origins of the Armed Forces Medical Examiner System.

The Armed Forces Medical Examiner System (AFMES) is the only medicolegal death investigation system of the US federal government. Its origins can be traced to three dried tissue specimens placed on a shelf by a Civil War Surgeon General in 1862. The collections and the library of the Army Surgeon General spawned the Armed Forces Institute of Pathology (AFIP), the National Museum of Health and Medicine, the Walter Reed Army Institute of Research, and the National Library of Medicine. Pathologists of the Army Medical Museum performed the autopsies of assassinated Presidents Lincoln and Garfield and assisted with that of Kennedy. The now defunct AFIP created the first forensic pathology training program approved by the American Board of Pathology and then the AFMES. Col Ed Johnston, CAPT Charlie Stahl, and Col Dick Froede were the original pioneers of the AFMES.