Medicolegal Death Investigation Research Articles

Skeletal Trauma: An Anthropological Review.

As anthropologists take on a larger role in medical examiner's offices, the incorporation of bone trauma analysis into the autopsy increases. The purpose of this invited review is to summarize recent anthropological literature that exemplifies the value of forensic anthropology in medicolegal death investigation, concentrating in the area of skeletal trauma analysis. Forensic anthropologists have a strong understanding of bone's response to trauma, gained through research and case studies. With this body of knowledge they are able to examine and interpret skeletal injury resulting from blunt, sharp, firearm, and thermal trauma. For example, toolmark class characteristics are recognized through sharp force injury examination, and fracture pattern analysis provides details of the impacting surface area. Interpretation of skeletal trauma allows for reconstruction of events surrounding death, and may inform the manner of death classification.

The Value of Anthropology in Medicolegal Death Investigation of Pediatric Nonaccidental Injury.

Forensic anthropologists have made remarkable contributions to the medicolegal investigation of nonaccidental injury in pediatric cases. They have created standard nomenclature for fracture descriptions. Anthropologists have developed novel techniques that increase the sensitivity of the pediatric autopsy. They have performed biomechanical research that enables reconstruction of events surrounding death. Also, anthropology practitioners have developed several reference guides on the subject of nonaccidental injury that are of value to forensic pathologists. These advancements assist forensic pathologists in the accurate classification of cause and manner of death in pediatric cases.

National Initiative to Prevent Suicide (NIPS): A New Proposal to Improve the Understanding and Prevention of Suicide.

Suicide is a staggering, tragic, and growing cause of death in the United States. Despite a government-led 20-year effort, the suicide rate increased by 25% between 1999 and 2014. To prevent suicide, it is essential to understand the biological factors-genetic and epigenetic-and environmental factors that underlie it. To gain this increased understanding, the equivalent of the "War on Cancer" initiative is needed. The War on Cancer initiative, which began in the 1970s, has transformed the treatments and outcomes of cancer, and the same could occur with a similar initiative on suicide. This article proposes a National Initiative to Prevent Suicide (NIPS), with the first step being the establishment of a National Suicide Database (NSD). The NSD would be established by a government-private partnership much as was done by the National Cancer Institute in the War on Cancer. The NSD would be established under the auspices of the National Institute of Mental Health and the Centers for Disease Control and Prevention. Approximately $600 million are currently spent annually by taxpayers in the United States to support the medicolegal death investigation system, composed of 3137 county coroner or medical examiner offices across the country. In their investigation of deaths due to suicide, these offices collect extensive information, including biological samples, from the >40,000 deaths due to suicide that occur each year. The proposal presented in this column calls for this material to be stored in the NSD so that vetted government and public/private researchers can investigate the causes of suicide. This information will make possible the development of new methods, including laboratory evaluations, for assessing suicide risk as well as new treatments to prevent suicide. In support of this proposed new initiative, this article/proposal reviews the current medicolegal death investigation system and recent advances in our understanding of the biological basis of suicide. The time for action on this proposal is now.

Forensic Archaeology and Forensic Taphonomy: Basic Considerations on how to Properly Process and Interpret the Outdoor Forensic Scene.

Medicolegal death investigation requires a multidisciplinary approach to the collection of data from the crime scene to the autopsy table. Law enforcement processing of the indoor crime scene works extremely well for documenting evidence and producing reconstructions of past events. However, outdoor crime scenes require a new set of scene processing protocols - a need primarily derived from the wider array of natural agents, such as plants, animals, soil chemicals, or environmental conditions that will affect the evidence after burial or deposition outdoors. Forensic archaeology provides the principles, practices, and protocols for documenting and analyzing this type of evidence at a variety of outdoor and other complex crime scenes, including large-scale scene searches, surface-scattered remains, buried body features, fatal fires, and mass disaster scenes. Scene recovery protocols require 1) documentation of the context of the scene, including specific location, local flora and fauna, and geological, geographic, and environmental factors and conditions and 2) detailed notation of the spatial distribution of the evidence in order to establish association of evidence to other evidence and to a particular incident. The discipline of forensic taphonomy provides the techniques and conceptual framework to combine these scene-derived data with laboratory analysis of the biological tissues in order to build and test scientific hypotheses regarding the events surrounding death and deposition. The primary assessments resulting from a forensic taphonomic interpretation include scientific estimates of postmortem interval; whether and how remains have been moved, removed, or altered; and ultimately, whether there is an indication of human intervention.

The circumstances and characteristics of fatal falls in Victoria, Australia: a descriptive study

Falls are the 18th major cause of death in Australia. The intention of this study was to provide a comprehensive understanding of fatal falls in an Australian context through documenting the circumstances of fall-related deaths and investigating the characteristics surrounding those falls. A retrospective review of fatal falls in the state of Victoria from 2005 to 2014 was undertaken using the National Coronial Information System online database. Details recorded for each fatal fall case comprised the circumstances of the fall (year and month of fall, fall type, and manner and cause of death) and characteristics of the deceased (sex, age, body mass index, pre-existing conditions and psychoactive drug use). There were 2743 fatal falls, encompassing falls from a bed, chair, height (>3 m), horse, ladder, low height (≤3 m), motor vehicle, stair(s), standing, toilet, wheelchair and unspecified. The majority of falls were accidental (95.5%), indirectly contributed to the fatality (66.4%), were female (53.2%), elderly (61+years) (92.3%) and of a healthy weight (33.3%). Many had pre-existing conditions (86.8%) and several (19%) had psychoactive drug use. Findings are anticipated to contribute to prevention policy improvements and assist medico-legal death investigations.

From Death to Death Certificate: What do the Dead say?

This is an overview of medicolegal death investigation and death certification. Postmortem toxicological analysis, particularly for ethanol and drugs of abuse, plays a large role in the forensic investigation of natural and unnatural deaths. Postmortem drug concentrations must be interpreted in light of the autopsy findings and circumstances. Interpretations of drug and ethanol concentrations are important for death certification, but they also may be important for other stakeholders such as police, attorneys, public health practitioners, and the next-of-kin.

The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System.

BackgroundMedico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS).MethodsPubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000–2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers.ResultsOf the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders.ConclusionsTo ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-016-0096-1) contains supplementary material, which is available to authorized users.

Leadership Decisions Influencing Medicolegal Death Investigation: “We wear a lot of hats.”

ABSTRACTLeaders of medicolegal death investigation agencies face leadership and management challenges. To develop a deeper understanding of how they approach these challenges in the context of the community they serve we explored their lived experiences through semi structured telephone interviews about the essential services of their agency. Qualitative interviews of 12 leaders were transcribed and reviewers identified major themes through multiple readings. The themes included: Responsibilities of Agencies, Interdisciplinary Relationships, Variations in Practice, Recruitment of Agency Personnel, Leaders Qualifications and Certification of Personnel, Training of Personnel, and Quality Improvement/Quality Assurance. The factors affecting agency leaders are complex ranging from the hiring of agency personnel to running and overseeing all aspects of death investigations. There are resources such as leadership training and mentoring needed to improve the oversight and quality of death investigation agencies ...

Decomposition Changes in Bodies Recovered from Water.

Recovering bodies from water is a common task for any medical examiner or coroner office. Unfortunately, there will be a significant postmortem interval before many of these remains are found. A thorough scene investigation must be undertaken to determine if the location of the death and that of the body recovery are the same. Decomposition in a wet environment differs from that in other settings, both in the changes that occur and the rate at which they occur. It is essential that the forensic pathologist or medicolegal death investigator recognize and appreciate the uniqueness of immersed and submerged remains. The typical decomposition changes proceed more slowly in the water, primarily due to cooler temperatures and the anaerobic environment. However, once a body is removed from the water, putrefaction will likely be accelerated. Postmortem changes are not only affected by water temperature, but also by current as well as obstacles and structures, both natural and man-made, that may interact with the remains. The anaerobic nature of decomposition for wet or submerged remains may result in adipocere formation, a unique and fascinating process that results from incomplete transformation of lipids by bacteria. Insect and animal species feeding on the remains are different for submerged bodies. Postmortem predation may cause external defects that mimic injuries and should be interpreted with care. Forensic pathologists and medicolegal death investigators must be aware of the postmortem changes that may occur with submerged and immersed bodies.

Artifactual aortic dissection as a result of post-mortem CT angiography

Abstract An 82-year-old woman who died unexpectedly at home was admitted to our institute for investigation into her cause of death. Extensive subarachnoid hemorrhage was identified on the admission post-mortem computed tomography (PMCT) scan. Subsequent post-mortem computed tomography angiography (PMCTA) utilizing embalming principles and equipment identified leak of contrast from the right middle cerebral artery indicative of ruptured aneurysm and this was confirmed at autopsy. Unexpectedly after autopsy, PMCTA review revealed a large intimal flap indicative of apparent extensive aortic dissection arising from the tip of the infusion cannula in the left femoral artery to the ascending aorta, rupturing into the pericardial sac. This was not in keeping with the admission PMCT and was not detected at autopsy, although aortic atherosclerosis was present. This finding mirrors a similar artifact recently described in the literature secondary to embalming. In this case, it appeared to be an artifact of the PMCTA technique due to mechanical disruption of the arterial wall at the point of cannulation with flow of contrast solution into both true lumen and aortic wall creating a false lumen. With increasing use of post-mortem imaging to assist in medico-legal death investigations, it is imperative that practitioners be aware of and take into consideration the post-mortem changes and artifacts that can be caused by and detected on such imaging. In addition, it is important that all cases undergoing PMCTA have a preliminary PMCT for comparison and that all imaging findings are presented to the pathologist prior to autopsy for correlation at dissection.

Buried Alive: A Case Report on Traumatic Asphyxia

The word asphyxia is of Greek derivation which means ‘a stopping of the pulse’. Any death is asphyxial in nature, but in a forensic pathology setting, asphyxia means interference with the exchange of oxygen and carbon dioxide in the body. Mechanical asphyxia (i.e. physical interference with breathing and or circulation) is frequently encountered in medico-legal death investigations[1] and one of the forms is traumatic asphyxia where exclusion of air from lungs is effected by mechanical fixation of chest in such a way that normal respiratory movements are prevented. The deaths due to traumatic asphyxia are often incorrectly attributed to blunt-force injuries, whereas the cause typically is asphyxia due to chest compression. Here, I present a case report of a 32-year-old married woman who died due to traumatic asphyxia when she was caught and pinned to the ground in between falls of earth, stones and other materials, when roof of her bedroom in which she was sleeping at night caved in. The autopsy findings along with circumstantial evidence, results in arriving of conclusion that the death occurred as a result of traumatic asphyxia. There are several clinical features of this condition which are described in the literature, a brief review of which is given in this article.

The Toolbox Approach to Forensic Pathology

Medical examiners are physicians tasked with conducting medicolegal death investigations to determine cause and manner of death. Although the autopsy is the most frequent tool utilized in these investigations and the one most often associated with the practice of forensic pathology, there is a wide variety of tools available to the medical examiner, whose statutory duty mandates death certification. We discuss the evidence supporting the usage of these myriad tools, ranging from the older techniques of scene investigation, microbial cultures, and toxicology to the cutting edge of medicine such as advanced imaging, molecular genetic studies, and biochemical analysis/metabolic testing. The forensic pathologist must select the correct tools for a particular investigation based on the evidence supporting their usage and a medical judgment of each tool's pretest probability to produce a useful result, its appropriateness for the case, and the resources required for its utilization. The incorporation of these techniques into the forensic pathologist's toolbox improves our ability to conduct thorough medicolegal death investigations beyond that which can be accomplished by invasive autopsy alone.

The Current and Potential Future Role of Postmortem Computed Tomography in Medicolegal Death Investigation

The development of whole body, high resolution postmortem computed tomography (PMCT) with three-dimensional depiction has led some authors to describe the concept of “virtual autopsy” as a noninvasive replacement to conventional autopsy. A realistic appraisal of the capabilities of PMCT suggests its true role is more complex – in some settings such as accidental blunt trauma it has the potential to circumvent conventional autopsy and in others such as severe burns or drowning, PMCT can act as a triage tool to determine if autopsy is required. In many other cases, PMCT has a role of adjunct to conventional autopsy. Despite its myriad potential applications, PMCT remains underutilized in many countries. This paper addresses the background of PMCT, and describes its strengths, weaknesses, and indications. It discusses the economic and logistical challenges to its introduction, and emphasizes the clinical cooperation between diagnostic radiologists and forensic pathologists, and the training initiatives that are necessary for its success.

The Future of the Forensic Pathology Workforce

According to many published reports, testimonials, research studies, and data collected, there are not enough forensic pathologists to serve the United States. Forensic pathologists are responsible for the medicolegal investigation of death. Such investigation includes death scene, history, autopsy, and determining the cause and manner of death. To get an idea of the workload of the forensic pathologist, retrospective data can be examined. The numbers alone reveal that there has been and remains a shortage in the forensic pathologist workforce. If the overall goal is to remedy this forensic pathologist shortage, strategies must be broad and long-term. Also, not all goals will have concrete metrics that can be quantified, such as to increase and improve public image. Some of the underlying problems, trends, future predictions, and possible solutions are discussed.

Model Medical Examiner Legislation

Medicolegal death investigation laws throughout the United States are a hodgepodge. They reflect different systems and different evolutions and are generally incoherent and not up to date. A thoughtful review of existing statutes and a thoughtful analysis could produce model legislation that could be brought to the legislatures of all states and territories for consideration in whole or in part. This article discusses various issues and thoughts that should be deliberated during the formulation and crafting of such model legislation.

Cognitive Bias in Medicolegal Death Investigation

Cognitive bias is a popular criticism of medicolegal death investigation. However, many of these criticisms are misplaced. Some have criticized the use of history into medical diagnosis. However, this criticism ignores the fact that the practice of forensic pathology is a medical discipline; it is not a simple mechanical test. History is an integral and necessary part of medical practice, and the lack of history is more dangerous than its use. Criticisms of manner determination often reflect an incorrect understanding of what manner is and what it is properly used for. Many criticisms wrapped in the flag of cognitive bias are in fact errors in scientific orthodoxy, real scientific disagreements, issues of ignorance, and lack of competence or certification, ethical lapses, and political pressure. Solutions that address cognitive bias do not address these issues. Many of the proposed solutions have not themselves been proven to be effective. Alternatives, such as intensive peer review, might address both cognitive bias and these other issues. Any proposed interventions should themselves be able to demonstrate a sound empirical basis.

Companion Cases in a Large Urban Medical Examiner's Office.

Companion death cases, as defined in this study, include 2 or more deaths that occur at the same location or 1 death at a specific location combined with 1 or more individuals transported from that same location to a hospital where death was pronounced within 1 hour of arrival. These types of cases can have multiple causes and manners of death. The Wayne County Medical Examiner's Office conducted a retrospective study of companion death cases that came into the office from mid 2007 to the end of 2014. The purpose of the study was to identify and examine patterns of companion death cases in a large urban area that would assist future companion death case investigations. Three hundred fifty deaths were found to be companion cases, including 135 pairs (2 connected deaths in the same location), 20 trios, and 5 quartets. Approximately 49% of companion case deaths were homicides. Approximately 30% of companion case deaths were traumatic accidental deaths. Around 14% of companion case deaths that were from the same scene location had different manners of death, including suicide, homicide, natural, and indeterminate. The remainder of companion death cases were either drug related or natural. Through this study, we have identified a pattern to these companion death cases and have concluded that it is important to conduct a thorough medicolegal death investigation of such cases to establish and elucidate the true circumstances surrounding these deaths.

The Forensic Anthropology Report: A Proposed Format Based on the National Association of Medical Examiners Performance StandardsP

Following the release of the 2009 National Academy of Sciences Report, forensic practitioners have been reviewing or developing their best practices, especially with regard to methods used in evidence testing. Standardization of reports and terminology, although recommended in the NAS Report, has been less of a focus to date. Subsequently, the National Commission on Forensic Science has posted an initial draft under the heading “Report Content” that summarizes the basic information required in a forensic specialty service provider report (www.justice.gov/ncfs/work-products#report). As indicated, the draft document addresses content, not format. Herein, the authors propose a format for forensic anthropology reports submitted to medical examiners/coroners, that is based on the performance standards established by the National Association of Medical Examiners (NAME) in 2005. Adopting such a format would provide greater uniformity and clarity across the many forensic disciplines involved in medicolegal death investigation.

Forensic investigation of cranial injuries due to blunt force trauma: current best practice

Forensic investigation of cranial injuries due to blunt force trauma: current best practice Elena F Kranioti,1,2 1Department of Forensic Sciences, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece; 2Edinburgh Unit of Forensic Anthropology, School of History, Classics and Archaeology, University of Edinburgh, Edinburgh, UK Abstract: Blunt force trauma is one of the most common injuries encountered by the forensic pathologist in a variety of scenarios such as transportation fatalities, jumping or falling from heights, blast injuries, and being struck by firm objects. Blunt force injuries located in the cranium are often associated with the cause of death which makes their examination of vital importance in the medicolegal investigation of death. This article aims to review the existing knowledge on the mechanism of cranial blunt force injuries and the associated fracture patterns in order to facilitate the interpretation of such injuries in skeletonized or heavily decomposed bodies where soft tissue is no longer available. Current developments on theory and practice are also discussed. Despite the evidenced progress made in the past decades, trauma analysis in medicolegal settings remains a very challenging task, especially in the absence of soft tissue. It is thus imperative to work toward developing repeatable and scientifically acceptable methods with known error rates, in order to meet the increasing demands of the judicial system on the admissibility of evidence and expert witness testimony. Keywords: cranial trauma, blunt force trauma, forensic anthropology, fracture, cranial injuries

Suicide by Hypothermia: A Report of Two Cases and 23-Year Retrospective Review

Hypothermia deaths are frequently accidental and associated with impairment by alcohol, injuries, mental illness, or natural disease. Hypothermia as a method of suicide is unusual, with only nine case reports in the scientific literature. In the early months of 2014, during one of the coldest winters on record, the Hennepin County Medical Examiner's office investigated and certified two unrelated cases of suicide by hypothermia; we describe the salient features of these cases. A retrospective review of all cases investigated by our office from January 1991-April 2014 identified 146 cases in which “hypothermia” or “environmental cold exposure” was listed as a cause of death, contributing condition, or mechanism of injury. Death investigation narratives and autopsy reports were reviewed to confirm hypothermia and evaluate for the presence or absence of characteristic hypothermia findings. In these cases the manner of death was certified as follows: 116 accident (79.4%), 15 undetermined (10.3%), 8 suicide (5.5%), 6 natural (4.1%), and 1 homicide (0.7%). Further examination of the eight suicide cases revealed that half were female and half were male, and most were younger individuals with only one decedent above 50 years of age. Four of these deaths were associated with drug toxicities, five were associated with additional self-inflicted injuries (blunt force, sharp force, and/or gunshot wounds), and none of them exhibited paradoxical undressing. It is important for medicolegal death investigation professionals to recognize that, while rare, hypothermia deaths may represent intentional injury, and suicide as a manner of death should be considered in all cases.