National Association Of Medical Examiners Research Articles

Causes of Death in the Presence of Law Enforcement in Johnson County, Iowa, 2011-2020.

Objectives. To examine sudden and unexpected or trauma-related deaths that occurred in the presence of law enforcement in Johnson County, Iowa, between 2011 and 2020. Methods. We identified deaths in the presence of law enforcement using definitions from the National Association of Medical Examiners. We obtained data, including demographics, cause and manner of death, toxicology results, and circumstances and location of event leading to death, from comprehensive medical examiner investigative reports. Results. There were 165 deaths that occurred in the presence of law enforcement: 114 were from a known disease, and 51 were either trauma related or the sudden, unexpected initial presentation of a previously unrecognized disease. Three deaths occurred in the context of physical restraint by law enforcement. Suicide was the leading manner of death among trauma-related deaths; the means of suicide was predictable based on in-custody (hanging) or precustody (firearm) circumstances. Conclusions. Our findings highlight the potential role of medical examiners and coroners in improving completeness of data on reporting death in the presence of law enforcement to public health agencies. (Am J Public Health. Published online ahead of print April 4, 2024:e1-e9. https://doi.org/10.2105/AJPH.2024.307616).

Review of the Determination of the Cause and Manner of Death, in Deaths Related to Medical Care

A death certificate (DC) can be considered a legal document and in terms of societal use, it is a public document. A DC includes facts such as the time and place of death, as well as judgments as to the cause and manner of death. Whether it pertains to facts or judgments, recording false information results in a false DC. According to the National Association of Medical Examiners (NAME) in the United States, it is acknowledged that there are varying opinions and approaches when it comes to classifying the manner of death. Therefore, it may require a final judgment, including input from the legal system. Generally, deaths resulting from complications that occur during drug administration or medical procedures are classified as natural deaths, while deaths due to unforeseen complications that occur suddenly, are categorized as accidental deaths. Applying this classification by NAME to the principles and legal precedents related to the duty of explanation and medical lowas of the Korean Medical Association, it is reasonable to classify deaths resulting from complication, during medical care, as natural death. However, if the death occurs due to injury or poisoning during medical care, it falls under external causes, according to the principle of following the primary cause. In conclusion, it is considered reasonable to classify complications that occur during medical treatment as natural deaths when they are foreseeable and within the accepted range of complications determined by medical standards at that the time.

National Association of Medical Examiners Position Paper: Recommendations for the Documentation and Certification of Disaster-Related Deaths.

Collecting and reporting accurate disaster mortality data are critical to informing disaster response and recovery efforts. The National Association of Medical Examiners convened an ad hoc committee to provide recommendations for the documentation and certification of disaster-related deaths. This article provides definitions for disasters and direct, indirect, and partially attributable disaster-related deaths; discusses jurisdiction for disaster-related deaths; offers recommendations for medical examiners/coroners (ME/Cs) for indicating the involvement of the disaster on the death certificate; discusses the role of the ME/C and non-ME/C in documenting and certifying disaster-related deaths; identifies existing systems for helping to identify the role of disaster on the death certificate; and describes disaster-related deaths that may require amendments of death certificates. The recommendations provided in this article seek to increase ME/C's understanding of disaster-related deaths and promote uniformity in how to document these deaths on the death certificate.

Organ Retention Litigation

The common practice of retaining organs and tissues after the autopsy dissection is a potential legal liability for forensic pathologists and the offices they work for. In 1988, a coroner and the coroner’s office were successfully sued for corneal procurements without the consent of the next of kin. That led to later lawsuits of forensic pathologists and medical examiner offices over the retention of brains for formalin fixation and neuropathologic examination without consent, although the autopsies were not consent based. National Association of Medical Examiners became involved in this ligation and filed numerous amicus briefs. These later lawsuits were not successful. After caselaw on the subject, such lawsuits have largely abated. Nonetheless, the threat of such lawsuits remains, and statutory language can be promulgated to mitigate the risk.

The Potential Value of Video Abstracts to Dissemination of (Some) Information From National Association of Medical Examiners Annual General Meetings.

The purpose of this study is to determine whether video abstracts posted online to a social media platform (Twitter) increased dissemination of poster-abstract content from National Association of Medical Examiners (NAME) annual general meeting. At NAME meetings (2018, 2019), 20 authors accepted invitations to record visual abstracts. These were subsequently tweeted with their permission. Results were analyzed to determine how many times the video in each tweet was viewed and the number of impressions generated by the tweet. The NAME provided the number of attendees from each meeting to compare with online exposure to tweets.Video views per tweet ranged from 34 to 824 with a mean of 338. Of the 20 tweets, 5 (25%) had 600 or more views. The number of impressions per tweet ranged from 192 to 4629, with a mean of 1811. Seventy percent (14) had 500 or more impressions. Average conference participation for the meetings was 501.Given the numbers of views and even higher number of impressions, there appears to be a substantial increase in dissemination of poster abstracts beyond the conference attendees. The NAME should encourage authors of accepted abstracts to submit video summaries of their work. This will advertise forensic pathology research to a wider audience.

Correctly Identifying Deaths Due to Drug Toxicity Without a Forensic Autopsy.

In 2005, the National Association of Medical Examiners approved the Forensic Autopsy Performance Standards. Standard B3.7 indicates that a forensic pathologist shall perform a forensic autopsy when the death is by apparent intoxication by alcohol, drugs, or poison.The Jefferson County Coroner/Medical Examiner Office has observed an increase in our caseload by 10% per year since 2012. We designed a study to determine if a pathologist could correctly classify the cause of death (COD) and manner of death (MOD) of suspected drug-related deaths without information from the internal examination. The determination of the COD and MOD was then compared with the case file, which includes information from the internal examination and microscopy, to determine agreement between the case file and the reclassification. The percent correct for COD and MOD was calculated, and kappa values were calculated for MOD.The pathologists were able to correctly classify the COD in 73% of cases. For MOD, 2 pathologists achieved substantial agreement between the test cases and the actual case file. The third pathologist had moderate agreement. These findings indicate that a full postmortem examination is necessary to correctly classify the COD/MOD in cases of suspected drug toxicity.Our null hypothesis is that a full autopsy is not necessary to correctly classify the COD and MOD in cases of drug toxicity.

Genetic Counselors' Approach To Postmortem Genetic Testing After Sudden Death: An Exploratory Study.

A significant portion of sudden death cases result from an underlying genetic etiology, which may be determined through postmortem genetic testing. The National Association of Medical Examiners (NAME) recommends that an appropriate postmortem sample is saved on all sudden death cases under the age of 40. Genetic counselors (GCs) play an important role in this process by working with medical examiners and coroners (ME/Cs) to recommend and interpret specific testing and to guide family members. A survey sent to the National Society of Genetic Counselors was designed and implemented to learn more about the experiences of genetic counselors who had considered or ordered postmortem genetic testing. Results showed that cardiovascular GCs were significantly more willing to recommend genetic testing in younger age decedents (ages 10, 18, 30, 40, and 50) compared to other specialty GCs (p<0.05, Chi-square). Thirty-seven percent (7 of 19) of GCs reported insurance covering some portion of genetic testing. Participants also reported highest success for DNA extractions with fresh and frozen blood, reinforcing NAME recommendations for appropriate sample collection for postmortem genetic testing. Overall, participating GCs demonstrated a very good understanding for the appropriate use of postmortem genetic testing and did identify suspected barriers of cost and lack of insurance coverage as deterrents. With the rapid decrease in costs for diagnostic genetic testing, ME/C awareness of NAME recommendations for sample collection and storage remain important to facilitate postmortem genetic testing.

National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy.

Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.

National Association of Medical Examiners position paper: Recommendations for the investigation and certification of deaths in people with epilepsy.

Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered.

National Association of Medical Examiners Position Paper: Recommendations for the Definition, Investigation, Postmortem Examination, and Reporting of Deaths in Custody.

The National Association of Medical Examiners commissioned an ad hoc committee to provide recommendations for the investigation, examination, and reporting of deaths in custody. Deaths in custody, whether occuring in jail/prison or during an altercation with law enforcement, is a complex issue and requires the forensic pathologist to be knowledgable and deliberative about his/her diagnosis. This paper provides recommendations for the forensic pathologist as it relates to 1) categorization of deaths in custody, 2) critical information required during investigation, 3) enhanced autopsy procedures, 4) guidance on death certification, 5) parameters for statistical reporting, and 6) release of information to the public. A uniform approach by medical examiners and coroners to the investigation and evaluation of deaths in custody is critical. The establishment of recommendations has the potential to ensure consistency and reliability to the definition, investigation, and certification of these cases. Such uniformity and consistency will instill confidence in the independence of the medical examiner/forensic pathologist/coroner by the criminal justice system, public health system, and community at large.

A Fresh Look at the History of SIDS.

Sudden infant death syndrome (SIDS) became a named entity in 1969 and the term has been used to certify sudden unexpected infant deaths meeting certain demographic, epidemiologic, and pathologic criteria. Since it is a diagnosis of exclusion, there is inherent imprecision, and this has led the National Association of Medical Examiners to recommend that these deaths now be classified as "undetermined." This historical review article briefly analyzes anecdotal instances of SIDS described centuries ago as overlying, smothering, infanticide, and suffocation by bedclothes followed by a more detailed review of "thymic" causes (i.e., thymic asthma and status thymicolymphaticus) popular in the late 1800s and early 1900s. Before the 1950s, such cases were also often categorized as accidental mechanical suffocation. In the 1940s and 1950s, forensic studies on infants dying unexpectedly revealed a typical pattern of autopsy findings strongly suggestive of natural causation and, after 1969, cases meeting the appropriate criteria were usually categorized as SIDS, a term embraced by the public and by advocacy groups. Research conducted after the 1960s identified important risk factors and generated many theories related to pathogenesis, such as prolonged sleep apnea. The incidence of SIDS deaths decreased sharply in the early 1990s after implementing public awareness programs addressing risk factors such as prone sleeping position and exposure to smoking. Deletion of cases in which death scene investigation suggested asphyxiation and cases where molecular autopsies revealed metabolic diseases further decreased the incidence. This historical essay lays the foundation for debate on the future of the SIDS entity.

Recommendations for the Autopsy of an Infant who has Died Suddenly and Unexpectedly.

As the result of improved death scene investigations and the performance of more thorough and thoughtful pediatric forensic autopsies, there has been a widespread increase in the recognition of asphyxial mechanisms of death as well as lethal natural diseases that might have otherwise been erroneously labeled as sudden infant death syndrome (SIDS) or sudden unexpected infant death (SUID). Although it is fair to state that "more thorough autopsies provide more thorough medical evidence" from which to draw upon when determining cause and manner of death, there is no standard, accepted baseline from which forensic pathologists operate. Although anatomic pathologists are quite accustomed to practicing within well-defined boundaries for specimen (and thus diagnostic) adequacy, forensic pathologists are frequently hesitant to embrace or adopt such concepts. This has made it difficult to evaluate standards of practice in forensic pathology. Recommendations have been developed and published by the National Association of Medical Examiners for the postmortem assessment of suspected infant head trauma. However, significant variation exists in the way autopsies are performed on infants without trauma, such as the common scenario of an infant who has died suddenly and unexpectedly of asphyxial or apparent natural means. A wide variety of autopsy techniques and ancillary studies are available to forensic pathologists, but as survey data indicates, are not consistently used throughout the United States. This paper will discuss the different components of the pediatric autopsy and make recommendations for the best use of available tests and consultation services.

A Ten-year Study of Suicides from a Rural/Suburban County.

This study will discuss trends in suicide data compiled over 10 years in Dutchess County, NY, from 2004 to 2013. These data were based on reporting and examination standards recommended by the National Association of Medical Examiners and Department of Justice death investigation standards. Almost 300 cases were analyzed in terms of the deceased's gender, age, race, method of suicide, and weapon used. Results from this study agree with other reports showing significant differences for method of death both in terms of age and gender, with men more likely to choose firearms and women more likely to choose overdose. Furthermore, older persons were more likely to commit suicide by firearms, and the younger persons were more likely to commit suicide by overdose. However, other areas, such as method of suicide, differ from national statistics.

An Alarming Situation of Suicide Patterns and Methods Involved in Pakistan

The act of deliberately killing an individual’s own life is known as suicide. Suicide is an important social issue and major cause of mortality Worldwide. The data was obtained from Pakistan Ordinance Factories (POF) Hospital WahCantt, Tehsil Headquarter hospital Taxila and Hassan Abdal, Pakistan. Retrospective study design was used to review suicidal cases during 2013-2014 in three health centers of Pakistan. “A Guide for Manner of Death Classification” was used for assessing the suicidal identification criteria by National Association of Medical Examiners. Chi-square test was applied to see the association between qualitative variables. A total of 100 cases were retrieved.The mean age was found to be 27.12±10.11 years. The peak age of suicidal attempts was seen in 20-30 years of age. The suicidal rate was found to be higher among males 29.99±12.73 than females 23.03±7.669. Study found out that suicide methods among all cases are 40% drug overdose, 20% wrist cutting, 10% hanging, 10% jumping from height, 10% chemical poising and 10% suicidal burns. The suicide rate is higher among Pakistani population but it was underestimated due to lack of reporting, cultural and religious reasons. Effective prevention requires a clear understanding of the size of the problem, its distribution in the population, and the major risk and protective factors at the levels of the individual, the family and the community.

Dissecting and Streamlining the Medical Record Acquisition Process in Death Investigation Systems.

Though medicolegal death investigation (MDI) systems are generally associated with criminal justice, they serve an integral role in the realm of public health and safety. Medicolegal death investigation offices collect information, including medical records, from a variety of outside sources. For data to travel efficiently, transmission should be fully integrated between the MDI office and external organizations. This is often not the case. Delays in the transmission of medical records in particular lead to subsequent delays in autopsy report completion and death certification or to resource waste in cases where a timely record would have let the pathologist know an autopsy was not required. Almost no peer-reviewed literature currently exists regarding the problem of record acquisition by MDI systems. To develop a better understanding of how electronic medical records have impacted MDI systems, we conducted a mixed methods survey through the National Association of Medical Examiners (NAME) e-mail listserv. We inquired about the medical records acquisition processes at MDI systems around the nation to gauge opinions about the use of electronic health data and the integration of MDI data in public health. Concurrently, we piloted a quality improvement project at the Alameda County Sheriff-Coroner's Office (ACSCO) in Oakland, California, in which we worked with various hospitals to get ACSCO employees direct access to decedents' electronic health records. With data from the survey and pilot project, we were able to document the barriers encountered when attempting to reform medical record acquisition and to suggest systemic changes to reduce delays and wasted resources.

Forensic Pathologist Consensus in the Interpretation of Photographs of Patterned Injuries of the Skin.

Forensic pathologists are commonly asked to evaluate injuries on the basis of photographs. Members of the National Association of Medical Examiners were asked to participate in an online survey in which they were presented with 68 patterned injuries of the skin and asked to make a diagnosis ranging from very general (e.g., "blunt" vs. "sharp") to specific (e.g., "baton blow"). This was not the case. Consensus for general diagnosis averaged 0.77 and 0.72 for specific diagnosis. While there was a strong correlation between consensus and confidence in aggregate, individual correlations were poor. Consensus diagnosis was inversely correlated with age, and positively correlated with jurisdictional size, medical degree, and whether or not the respondent was actively performing autopsies as a job function. A subsequent survey is exploring possible reasons for lack of consensus in low-consensus questions. The high correlation between confidence and consensus at the aggregate level and low correlation at the individual level may have implications for quality assurance protocols.

Effectiveness of Mortuaries in Turkey: A Questionnaire Study.

The autopsy is an important step in solutions of forensic cases. The design and effectiveness of mortuaries are of great importance in terms of proper conduction of death examinations and autopsies. In addition, the safety of evidence, protection of public and staff health, and the quality of service offered to relatives of dead people are closely related to the effectiveness of mortuaries. The aim of this study was to determine whether mortuaries in Turkey meet international criteria. Nineteen mortuaries were included in the study. The forensic medicine experts working in these mortuaries were given a questionnaire composed of questions about standards developed by the National Association of Medical Examiners (NAME) through the website my.questbase.com. Most of the mortuaries outside big cities (80%) did not have their own facilities. All of them could not control the chain of evidence and did not have a separate well-ventilated autopsy room where they could keep putrefied corpses. Most of the mortuaries did not meet most of the NAME criteria. The mortuaries, especially those in places other than big cities, had some deficiencies and mishandlings. Autopsy facilities and accessory laboratories should be enabled to meet NAME accreditation standards.

Forensic Pathology Workload and Complexity: Designing a Complexity System that Accurately Represents Workload

For the most part, workload is defined for forensic pathologists in North America by the number of cases per annum, with specific recommendations set out by the National Association of Medical Examiners (NAME) to perform no more than 250 autopsies in a year. However, this definition of workload is somewhat limiting as it doesn't reflect the case to case variability that forensic pathologists encounter. The variability translates into differing amounts of time needed on the part of the pathologist to devote to each case and those differences in time can be substantial. Complexity systems exist in surgical pathology to better reflect the case-to-case variability that surgical pathologists experience. Based on these complexity systems, departments can have a more accurate representation of workload and appropriately allocate resources and plan staffing. Many different complexity systems exist, but all of them, in their own way, attempt to lessen the gap between overvaluing simple specimens and undervaluing complex specimens. No formal system for gauging complexity exists in forensic pathology. The creation of one would provide a more detailed taxonomy to be better able to define forensic pathologists' workload and compare workload between pathologists and institutions.

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.

Tracking the Opioid Drug Overdose Epidemic in King County, Washington Using an Improved Methodology for Certifying Heroin Related Deaths

Guidelines of the National Association of Medical Examiners recommend that death certificates of overdose deaths list specific drugs. While this is important in tracking the national opioid drug overdose epidemic, differentiating heroin from morphine as the source drug remains problematic. To distinguish the two, a specific methodology was developed for death certification based on a combination of toxicology testing and scene investigation. This study evaluates the methodology in assessing the contribution of heroin. In two decades in King County, there were 3369 opioid drug overdose deaths, ranging from 139 in 1995 to 233 in 2014. In the 1990's, opioid overdose deaths were predominantly due to heroin; deaths due to prescription opioids were relatively uncommon. This trend reversed around 2003 with overdose deaths due to heroin declining and those due to prescription opioids increasing. The trend again reversed around 2012 with resurgence of heroin and declining deaths due to prescription opioids. Before the specific methodology was employed, it was known that heroin was the predominant opioid, but the summary data did not differentiate morphine and heroin. After adopting the methodology in 2004, the data reasonably tracked the contribution of heroin: out of 2125 opioid deaths, 34% were due to heroin, ranging from 14% in 2009 to 65% in 2014. The results of this study show an overall increase in opioid deaths and an inverse relationship between heroin and the prescription opioids. Furthermore, the specific methodology for certifying heroin deaths greatly improves accuracy in tracking opioid overdose deaths.