Medicolegal Death Investigation Research Articles

Causes of death determined in medicolegal investigations in residents of nursing homes: a systematic review.

To systematically review published research characterizing the nature and circumstances surrounding the death of older people in nursing homes specifically using information generated for medicolegal death investigations. Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement using the key words death, nursing homes, and medicolegal death investigation. Cross-sectional data from original, peer-reviewed articles published in English between 2000 and 2013 describing deaths of nursing home residents. Information was extracted for analysis about study and population characteristics, number and type of deaths, study design, findings, and limitations. Thirteen studies were identified. The studies examined external causes of deaths from suicide, choking, restraint or bed-related injuries, falls, and pressure injuries. Deaths were more frequent in women with existing comorbidities. Suicide was predominant in men. Identified risk factors and opportunities to reduce harm were identified at individual, organizational, and structural levels. Overall, the quality of the studies limited the aggregation and comparability of findings. This systematic review informs researchers, clinicians and policy-makers about how to reduce external causes of death in nursing homes.

To hold or not to hold: medicolegal death investigation practices during unexpected child death investigations and the experiences of next of kin.

The purpose of this study was to identify the current practices within the medicolegal death investigation system, as well as the experience of bereaved parents due to sudden unexpected child death with regard to viewing, memorial keepsakes, and communication during the death investigation. Convenience samples of 197 professionals and 156 bereaved parents participated. Respondents were asked to participate in an online survey. Results show that the majority of professional respondents (96.5%) allow the next of kin (NOK) to view his/her child before transport to the morgue while holding the infant/child was somewhat less commonplace (68.9%). The majority of professional respondents (70.4%) would also permit memorial keepsakes to be made. Additional factors are explored that both hinder and promote these common family requests. Furthermore, professional practices and NOK experiences in regard to communicating preliminary and final cause of death information to the NOK were highly variable. This article provides a snapshot at the current death investigative practices in the United States, as well as how these practices are received by NOK along with their recommendations for change. These results may be used to further inform future guidelines to improve comprehensive and efficient death investigations that support the emotional needs of the newly bereaved.

Can Forensic Pathologists Diagnose Pulmonary Thromboembolism on Postmortem Computed Tomography Pulmonary Angiography?

Postmortem computed tomography (CT) scanning is a routine examination in the medicolegal death investigation of every deceased person admitted to the Victorian Institute of Forensic Medicine. Pulmonary CT angiography is a standard clinical investigation for suspected pulmonary thromboembolism. To the best of our knowledge, a study of postmortem CT pulmonary angiography has not been previously reported in the English-speaking forensic literature. We present our findings on 13 cases of suspected massive pulmonary thromboembolism where forensic pathologists assessed postmortem CT pulmonary angiography, which were then correlated with conventional postmortem examinations.

A Perspective on Medicolegal Death Investigation in the United States: 2013

The status of medicolegal death investigation in the United States is reviewed based on the literature, reports, surveys, and vital statistics data. The vast majority of chief medicolegal death investigation system officers are coroners, but the majority of the U.S. population is served by medical examiner systems. Conversion of coroner systems to medical examiner systems has come nearly to a halt. More forensic pathologists are needed to enable autopsy performance at a rate of one per thousand population and comply with the National Association of Medical Examiners (NAME) standards regarding autopsy caseload. Efforts are needed to recruit and retain forensic pathology trainees in the specialty of forensic pathology. More medicolegal death investigators are needed and measures need to be taken to train and certify more of them. Regional medicolegal death investigation and autopsy centers are needed in some parts of the country and some areas of the U.S. lack ready access to forensic pathologists. Only a small portion of medical examiner and coroner offices is accredited by NAME or the International Association of Coroners and Medical Examiners (IAC&ME). Medical examiner/coroner death certification and autopsy rates in the states vary considerably, probably due to variations in statutes, funding, staffing, practice preferences, and practice patterns that have evolved through tradition and custom. Although death investigation in the United States seems to be adequate to meet basic needs in the various states, there is room for further improvement in the scope and quality of service and manpower.

A Synopsis of the 1928 National Research Council's Bulletin on “The Coroner and the Medical Examiner”

The 1928 National Research Council (NRC) Bulletin on “ The Coroner and the Medical Examiner” is an often-referenced report because it compares the two system types and recommends that coroner systems be abolished and replaced with medical examiner systems. Copies of the Bulletin are difficult to find, so this article provides a synopsis of the Bulletin's content. The NRC Bulletin 64 was prepared under the auspices of the seven-member “Committee on Medicolegal Problems.” The report itself begins with a historical summary of the coroner system and discussion of the medical and judicial duties of coroners, along with the inadequacy of existing autopsy facilities. Next is a review of previous surveys of coroner systems in New York City, Cleveland, and Missouri. The Committee conducted its own surveys of the coroner systems in New Orleans, San Francisco, and Chicago. The Committee also studied the medical examiner systems in Boston, other parts of Massachusetts, and in New York City. Other sections deal with the comparative costs of the two systems, teaching of forensic medicine, medicolegal institutes, scientific publications, a summary of defects of coroner systems and advantages of medical examiner systems, and eight summary recommendations. We must remember that the historical Bulletin was written nearly a century ago, and there has been much improvement in medicolegal death investigation since that time, many improvements having their roots in the NRC Bulletin recommendations. The Bulletin's recommendations have been fulfilled to various extents in many parts of the United States.

Florida's Medicolegal Death Investigation System: A Brief History of the Medical Examiners Commission

Throughout Florida history, death investigations were performed under a haphazard or nonexistent system of justices of the peace coroners. These investigations were restricted to certain types of criminal deaths and deaths in jail, ignoring the vast majority of unexpected or violent deaths. There had not been a provision for the investigation of the large number of sudden, natural and violent deaths that fall into the non-criminal, yet public interest, category. Few states have an oversight and regulatory body such as Florida's Medical Examiners Commission. Its purpose is to advise medical examiners and to develop policies and procedures for how medicolegal death investigation is performed in the state. This article describes the formation and function of our Medical Examiners Commission and its membership, and also briefly describes other states that have a regulatory commission or similar governing body.

Beyond suicide: action needed to improve self-injury mortality accounting.

Beyond suicide: action needed to improve self-injury mortality accounting.

Justices of the Peace and Medicolegal Death Investigation: A Situation Unique to Texas

Death investigation throughout the United States is conducted by medical examiners, coroners, or combined systems, based on the laws of individual states. Larger counties in Texas employ medical examiners, but smaller counties rely on justices of the peace. Texas is unique in the use of justices of the peace in the place of county coroners. These justices have multiple responsibilities, including small claims courts, civil marriages, and inquests and death certification. In Texas counties with medical examiner offices, the justice of the peace relinquishes the responsibilities of death investigation and certification.

State Medical Examiner Systems, 2013: Staffing, Autopsies, Strengths, Limitations, and Needs

The medicolegal death investigation system of the United States is undergoing a national review aimed at improving it. It currently is a mixture of medical examiner and coroner systems organized by state and county. There are 24 states with a chief medical examiner overseeing the death investigation system of the state. These chief medical examiners were surveyed to collect data on system strengths, weaknesses, improvement needs, annual autopsy numbers, and current staffing levels. A recent Scientific Working Group for Medicolegal Death Investigation report has recommended a targeted goal of one medicolegal autopsy per thousand population (or roughly 10% of all deaths). For the 24 states, approximately 155 additional forensic pathologists (each performing up to 250 autopsies per year) would be needed to conduct autopsies at a rate of one per thousand population per year. Only four of the 24 states have an adequate number of forensic pathologists.

Coroner versus Medical Examiner Systems: Can We End the Debate?

This article is a discussion and comparison of coroner systems and medical examiner systems. Each type of system has potential merits and drawbacks, and virtually all systems face certain problems and challenges and could be improved. The arguments about coroner versus medical examiner systems have gone on for nearly a century, coroner and medical systems remain, and we need to shift our focus from our differences to those goals that we share. We believe the best approach is for each state and its various death investigation jurisdictions to thoroughly study its death investigation system to determine whether it is meeting the needs of the criminal and civil justice system, the courts, prosecution (plaintiff) and defense attorneys, public health and safety agencies, the medical community, and other interested users such as researchers and those interested in prevention strategies. It is also critical that jurisdictions ensure their medicolegal death investigation systems become accredited, their personnel become certified, and that they are following nationally accepted guidelines, standards, and best practices. If there are deficiencies, then the state, in conjunction with local jurisdictions, can decide what changes may be needed and which options are available to implement those changes. Again, the issue is not necessarily one of system type, but rather, the adequacy of support and manpower to function professionally and to meet the needs of users.

California: Home of the Sheriff-Coroner

The great majority of counties in California have elected sheriff-coroners conducting medicolegal death investigations. State law enabling such a combination of official duties, favorable administrative structures, available staffing, funding and training issues have supported the intra-state spread of this death investigation system. Criticism of death investigation systems lead by officers whose primary duty is policing have centered on the perception of a conflict of interest in deaths investigated criminally by the sheriff-coroner and in deaths in the custody of the sheriff-coroner. Though such deaths are intermittently publicized and questioned in the media, no objective data has been collected and reported to support or refute such concerns.

Cardiac channelopathy testing in 274 ethnically diverse sudden unexplained deaths

Sudden unexplained deaths (SUD) in apparently healthy individuals, for which the causes of deaths remained undetermined after comprehensive forensic investigations and autopsy, present vexing challenges to medical examiners and coroners. Cardiac channelopathies, a group of inheritable diseases that primarily affect heart rhythm by altering the cardiac conduction system, have been known as one of the likely causes of SUD. Adhering to the recommendations of including molecular diagnostics of cardiac channelopathies in SUD investigation, the Molecular Genetics Laboratory of the New York City (NYC) Office of Chief Medical Examiner (OCME) has been routinely testing for six major channelopathy genes (KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, and RyR2) since 2008. Presented here are the results of cardiac channelopathy testing in 274 well-characterized autopsy negative SUD cases, all with thorough medicolegal death investigation including complete autopsy by NYC OCME between 2008 and 2012. The cohort consisted of 141 infants (92.9% younger than six-month old) and 133 non-infants (78.2% were between 19 and 58 years old). Among the ethnically diverse cohort, African American infants had the highest risks of SUD, and African American non-infants died at significantly younger age (23.7 years old, mean age-at-death) than those of other ethnicities (30.3 years old, mean age-at-death). A total of 22 previously classified cardiac channelopathy-associated variants and 24 novel putative channelopathy-associated variants were detected among the infants (13.5%) and non-infants (19.5%). Most channelopathy-associated variants involved the SCN5A gene (68.4% in infants, 50% in non-infants). We believe this is the first study assessing the role of cardiac channelopathy genes in a large and demographically diverse SUD population drawn from a single urban medical examiner's office in the United States. Our study supports that molecular testing for cardiac channelopathy is a valuable tool in SUD investigations and provides helpful information to medical examiners/coroners seeking cause of death in SUD as well as potentially life-saving information to surviving family members.

Medico-Legal Death Investigation Systems in the Pacific and Creating a Stronger Pacific Disaster Victim Identification Network

Introduction: The Pacific Island Countries (PICs) consist of 20,000 to 30,000 scattered islands spread across 8.5 million square kilometers of Ocean. There are three ethnogeographic distinct sub-groupings in the Pacific and they are Polynesia, Melanesia and Micronesia. The evolution of the global Medico-Legal Death Investigation (MDI) system has produced the Coroner's, Medical examiner's and the newer European Continental systems. However, the PICs maintain post-colonial mixed medico-legal systems. Disaster Victim Identification (DVI) is an important part of the MDI system. Objective: To review the MDI systems in the PICs and the recommend measures accordingly to strengthen the network for DVI in the Pacific. Methods: This is a qualitative research paper focusing on independent self-governing PICs from Polynesia, Melanesia and Micronesia. Discussion: The PICs criminal codes, legal systems and post-colonial adaption of MDI systems are emerging. There are also many developmental limitations for MDI systems in the PICs. Despite the profound historical evidence of disasters of varying magnitudes, the Pacific MDI and DVI network exists as an informal one through personal acquaintance. Therefore, this demands a better and effective MDI system in the PICs particularly with regards to DVI. Conclusion: The need to fortify and better the DVI network in the Pacific will depend on good regional indicators. There is a crucial need for the operatives of the MDI system in the PICs to form a link through intergovernmental participation and association with other Pacific networks to drive the sustained development of the national and regional MDI system. Through this collaboration the Pacific DVI network could also be established centrally in a PIC that has a steady Forensic Science Service. Upcoming Forensic experts could operate out of this central location to serve the PICs accordingly. This eventually will achieve a standard practice and regionalization of the Pacific MDI network.

Consideration of Occupational Lung Disease and Pneumoconiosis in Forensic Pathology

Reports of workers stricken with lung disease sustained during the course of their employment date to antiquity. Despite stringent regulations to mitigate all manners of work place hazards, and the emergence of agencies and physicians engaged in the advancement of occupational health, occupational lung disease remains a significant problem within modern society. Inhalation of dusts and fumes sustained in the course of one's occupation may lead to significant morbidity and mortality, and lead to a huge cost to society in terms of lost productivity, medical care for the worker, and litigation. In certain circumstances, the identification of an underlying occupational lung disease may constitute a significant finding in medicolegal death investigation. This article will present an overview of common occupational diseases likely to be encountered in the practice of forensic pathology, based on the particular etiologic agent and occupational means of exposure.

Introducing standardized protocols for anthropological measurement of virtual subadult crania using computed tomography

Objectives This study introduces and assesses the precision of a standardized protocol for anthropometric measurement of the juvenile cranium using three-dimensional surface rendered models, for implementation in forensic investigation or paleodemographic research. Materials and methods A subset of multi-slice computed tomography (MSCT) DICOM datasets (n=10) of modern Australian subadults (birth—10 years) was accessed from the “Skeletal Biology and Forensic Anthropology Virtual Osteological Database” (n>1200), obtained from retrospective clinical scans taken at Brisbane children hospitals (2009–2013). The capabilities of Geomagic Design X™ form the basis of this study; introducing standardized protocols using triangle surface mesh models to (i) ascertain linear dimensions using reference plane networks and (ii) calculate the area of complex regions of interest on the cranium. Results The protocols described in this paper demonstrate high levels of repeatability between five observers of varying anatomical expertise and software experience. Intra- and inter-observer error was indiscernible with total technical error of measurement (TEM) values ≤0.56 mm, constituting <0.33% relative error (rTEM) for linear measurements; and a TEM value of ≤12.89 mm2, equating to <1.18% (rTEM) of the total area of the anterior fontanelle and contiguous sutures. Conclusions Exploiting the advances of MSCT in routine clinical assessment, this paper assesses the application of this virtual approach to acquire highly reproducible morphometric data in a non-invasive manner for human identification and population studies in growth and development. The protocols and precision testing presented are imperative for the advancement of “virtual anthropology” into routine Australian medico-legal death investigation.

Acute influence of alcohol, THC or central stimulants on violent suicide: A Swedish population study.

Alcohol and substance abuse in general is a risk factor for suicide, but very little is known about the acute effect in relation to suicide method. Based on information from 18,894 medico-legal death investigations, including toxicological findings and manner of death, did the present study investigate whether acute influence of alcohol, tetrahydrocannabinol (THC), or central stimulants (amphetamine and cocaine) was related to the use of a violent suicide method, in comparison with the nonviolent method self-poisoning and alcohol-/illicit drug-negative suicide decedents. Multivariate analysis was conducted, and the results revealed that acute influence of THC was related to using the violent suicide method–– jumping from a height (RR 1.62; 95% CI 1.01–2.41). Alcohol intoxication was not related to any violent method, while the central stimulant-positive suicide decedent had a higher, albeit not significant, risk of several violent methods. The study contributes with elucidating suicide methods in relation to acute intoxication.

Forensic investigation of suicide cases in major Greek correctional facilities

IntroductionAccording to Greek legislation the medico-legal investigation of deaths occurring in prisons is mandatory. Furthermore, in cases of suicide or of suspected suicide the contribution of medico-legal investigation is of grave importance. The current paper addresses the medico-legal investigation of suicide cases in Greek correctional facilities and aims to describe the current situation. Materials & methodsOur study consists of the meticulous research in the data records of major Greek correctional facilities, for the time period 1999–2010. Official permission was obtained by the Hellenic Ministry of Justice, which provided us the access to the records. Data was also collected from the Piraeus Forensic Service, from the Department of Pathological Anatomy of the University of Athens and finally from our own records. Measures were taken to respect the anonymity of the cases. Data was collected for the social, penal, medical history as well as for the medico-legal investigation. Results–conclusionsIt appears that 85.7% of suicide cases were transferred to the Prisoner's Hospital (p < 0.0001), the forensic pathologist who conducted the PME did not perform scene investigation in none of the 70 suicide cases. In a total of 70 cases, histopathological examination, was requested only in 30 cases (42.9%). Hanging was the preferred method for those who committed suicide, followed by the poisoning due to psychoactive substances.Understanding the mistakes made during the forensic investigation of suicide cases inside correctional facilities is necessary, in order to prevent them from occurring again in the future, by implementing appropriate new policies and guidelines.

Applications of Social Network Media in Medicolegal Death Investigation

With the increased popularity of online social networking services (SNS) such as Facebook, LinkedIn, Twitter, and Google+, we propose that a wealth of new resources is available for medicolegal death investigation. Recognizing this potential, we identified cases in which social media had been useful in the past in our office and asked our investigative staff to consider using social media in current cases. These cases provided illustrative examples for this primer regarding how information from SNS was used in death investigations in our office. Information gleaned from online social media aided in establishing preliminary identification of a decedent, locating next-of-kin, investigating the circumstances of death as relevant to the manner of death, corroborating eyewitness accounts, and providing information relevant to time of death. Potential pitfalls were identified, such as shared accounts or online impostors. SNS proved useful to the medicolegal death investigator and medical examiner, so long as their limitations were recognized.

Forensic Dentistry as a Morphological Exercise in the Medico-legal Investigation of Death

INTRODUCTIONIn one of the first scenes of the American thriller film“The Silence of the Lambs”, young FBI agent ClariceStarling is assigned to investigate the body of Buffalo Bill’srecently discovered victim. When Starling helps perform theautopsy, she manages to identify and extract the chrysalis ofa death’s-head Hawkmoth (Acherontia atropos) from thevictim’s mouth. Eventually, this finding was an importantpiece of evidence which lead to the capture of the serialkiller. Less cinematographically, Wankhede (2000) reportsfour factual cases with the aim to underline that examinationof the oral cavity, trachea, hands and all injuries is a vitalpart of post-mortem investigation. In the first one, a case ofhanging, the suicide note was found in the oral cavity.In forensics, the nature of collected evidence makesanalysis in many disciplines complex. Each type of traceevidence requires a unique systematic approach, and eventhese approaches are significantly based on the size andmorphology of the evidence being examined. Sincemorphology is the part of the biology that studies the formof organic beings and the modifications or transformationsthat it experiments, thanatology (the study of death and itsmechanisms), and forensic pathology (the morphology ofthe cadaveric injuries), they justify the morphologicalperspective of the medico-legal analysis. Forensic pathologyis essentially a visual exercise (El-Nageh et al., 1999).Although the forensic dentistry is a well-recognizeddiscipline, the term “Forensic Oral Pathology” is used todefine the field of odontology that involves the“identification, documentation, recovery and preservationof all signs in soft and hard oral tissues to making availablethe legal evidence”. This approach is more integral andcomprehensive than the recognized but unjustly delimitated,

National Association of Medical Examiners Position Paper: Medical Examiner, Coroner, and Forensic Pathologist Independence

Objective Forensic pathologists play a vital role in the justice system in matters concerning questions of death. Science as applied in the justice system should be objective and neutral. Since the goals of medical examiners and coroners are to determine the cause and manner of death for certification and public health functions (goals different and distinct from the missions of law enforcement agencies), it is important that medicolegal death investigation be independent. Accurate investigation, examination, reporting, and testimony by forensic pathologists are important to determine the cause and manner of death of individuals who die under sudden, unexpected, or violent circumstances. These cases can become the focus of political or legal pressure by individuals or offices seeking to influence the pathologist's findings. This pressure, even if seemingly unsuccessful in an individual case, can introduce error, bias, and corruption into the medicolegal investigation process. This paper reinforces the principle that medical examiners, coroners and forensic pathologists should be allowed to perform medicolegal investigations free of these influences. Participants The ad hoc Committee on Medical Examiner Independence of the National Association of Medical Examiners (NAME), a self-selected volunteer committee, developed this position paper. The findings are based on surveys of the NAME membership regarding members’ experience with, and reaction to, outside influence. Evidence Surveys of NAME members revealed that medical examiner independence was important to most members. Over 70% of survey respondents had been subjected to pressures to influence their findings, and many had suffered negative consequences for resisting those influences. In a separate study, over 30% of respondents indicated that fear of litigation affected their diagnostic decision-making. In 2009, the National Research Council of the National Academies published recommendations to strengthen the forensic sciences; they specifically recommended that medical examiner and coroner offices should be independent from law enforcement agencies and prosecutors’ offices. Consensus Process This position paper represents the consensus of the ad hoc Committee on Medical Examiner Independence, submitted to the Executive Committee and Board of Directors of NAME, and subject to comment and review by the membership. Conclusions It is the position of NAME that forensic pathologists working in or for medical examiner or coroner offices or as private consultants should be permitted to objectively pursue and report the facts and their opinions of those cases which they are investigating independent of political influences from other agencies within their respective jurisdictions and independent of the threat of litigation.