Facets of a Modern Death Investigation Office

The majority of ME’s offices are funded and chartered by government entities, such as counties, cities, or states. These organizations are established by statute, and function as agencies of that government. Typically, a chief medical examiner is appointed by the local city, county, or state executive, and he or she then appoints deputy medical examiners and other personnel as needed in order to meet the mission and statutory mandate of the office.

The personnel of the office are employees of the jurisdiction, and the office is funded by the county, city, or state. In some other jurisdictions, private forensic pathology medical groups are appointed as medical examiners by governments on a contract basis. In coroner jurisdictions, forensic pathologists may be employed by government coroners’ offices, or may be hired on a contractual basis to provide medical autopsy and examination services for the lay coroner. Small coroners’ offices may send decedents to a large medical examiner’s office or other medical facility for autopsy examination.

A key feature of any type of system is that the examinations performed by the medical examiner or coroner’s pathologist are done under the authority of the state, and as such, are not subject to approval of the decedent’s next of kin, as are diagnostic hospital autopsies. A corollary of this authority is that there can be no room in a medicolegal examination for objections to the forensic pathologist’s examination on personal or religious grounds.

If the ME or coroner has the need to conduct an examination in order to adequately investigate the death, then it should be done regardless of any objections, though the examination techniques may be modified at the discretion of the autopsy physician to attempt to accommodate family beliefs.

Any attempt to infringe upon this prerogative compromises the system of investigation significantly.
A medical examiner or coroner’s office must first determine whether a case reported to the office falls under its jurisdiction. Jurisdictional criteria vary according to law from state to state, but in general, deaths due to trauma or intoxication, natural deaths occurring suddenly and unexpectedly, or those due to unknown causes fall under the jurisdiction of the ME or coroner. Other types of death may not fall under ME or coroner jurisdiction, and need not be examined by those offices.

Sometimes there is a need for autopsy examinations in cases that do not fall under ME jurisdiction. At one time in the United States, the autopsy rate of individuals dying in a hospital setting approached 50%. The autopsy was viewed as a valuable diagnostic and quality assurance, and teaching tool, and permission was sought from the patient’s next of kin to perform an autopsy in most death cases. In cases not falling under a medical examiner or coroner jurisdiction, permission is required of the next of kin to perform an autopsy.

In recent decades, however, the autopsy rate in this country has plummeted, and now autopsies are performed infrequently in most hospitals, even in teaching institutions. This is due to a multitude of causes.
First, there is an over reliance on modern diagnostic imaging techniques and a belief that computed tomography and magnetic resonance imaging scans will have discovered everything the autopsy might find. This is proving to be a very erroneous belief, as most autopsy physicians can attest.

Imaging studies, in spite of their clinical utility, are poor substitutes for an adequate postmortem examination. Molina et al. have documented significant discrepancies between ante mortem imaging findings and the autopsy, which remains the gold standard of medical diagnosis. Second, the Joint Commission on Accreditation of Health Care Organizations deleted the autopsy requirement for hospital accreditation in 1971. This closely coincided with the precipitous drop in autopsy rates nationwide, as hospitals are no longer required to show a particular rate of autopsies in their institutions in order to be accredited.

The autopsy is not covered by third-party payers, or the payment is lumped under a general remuneration to a hospital without mandating actual autopsy rates, so there is no financial incentive to perform the examinations. Pathologists also tend to gravitate to other areas of practice that are not as time-consuming, less messy, and generate greater income.

As such, the autopsy today is practiced primarily in forensic pathology settings, such as medical examiners’ offices. Yet these offices have strictly defined limits on the types of cases they may take under jurisdiction, leaving a host of “medical” cases unexamined each year. These represent a true treasure trove of diagnostic and research data that go untapped in the United States.

Medical examiners’ offices vary in their organization, but it is possible to describe the organization and function of a “generic” office. A typical ME’s office will be divided into some or all of the following sections:
Investigations
Autopsy section
Toxicology laboratory
Clerical section
Administration

Investigations is in many ways the most important section of the medical examiner’s office. It is typically an investigator who takes initial reports of a death, and makes a determination as to whether or not the case falls under medical examiner jurisdiction. If it is determined that the case will be investigated by the ME, the investigator must then obtain more information about the circumstances of the case. The investigator will also take a leading role in helping to establish positive identification of the decedent. Identification techniques are discussed at length in a subsequent chapter, and are one of the most critical functions of any medicolegal examination. Just as a physician must take a medical history before examining or treating a patient, so must the forensic pathologist obtain background information on a death before examining a decedent. As the subject of the examination obviously cannot be interviewed, it is up to the investigator to gather this information from whatever source is available. This may involve visitation of the scene of death to photograph and describe findings. Often the position of the decedent may give critical information about the factors that lead to death. Conditions at the scene may implicate environmental factors in the death, or the finding of medications or intoxicants may result in suspicion of a drug-related demise. Indeed, interpretation of drug levels found in the body on toxicologic testing often relies heavily on scene or historical information about the decedent’s prior drug use. Scene findings, correlated with autopsy findings, often provide information about how a death occurred (manner of death), in addition to what caused the death. Apart from the scene investigation, investigators obtain other information regarding the medical history of the decedent by interviewing family members or acquaintances, or by obtaining medical records from hospitals or physicians. They may be responsible for transporting decedents from death scenes or hospitals to the ME office, fingerprinting bodies, inventorying personal effects and medications, and admitting and releasing bodies from the morgue. Alternatively, some or all of these duties may be shared with other sections of the office.

In large offices, the investigation section is usually composed of a number of full-time employees. In smaller offices, much of the investigative functions may be performed by the forensic pathologist or other staff.

The medical or autopsy section includes forensic pathologists and the technicians who assist them in performing examinations of decedents. These examinations may take the form of full or limited autopsy examinations, or be limited to external examination of the body.

The extent of the examination will be determined by the medical examiner after reviewing the decedent’s medical history and circumstances of death.

In elderly individuals or those with extensive and potentially fatal medical histories, found dead under circumstances that indicate a death due to natural causes, examination may be limited to external inspection of the body to exclude any evidence of trauma. On the other hand, in cases of acute traumatic death, particularly in the case of apparent homicide, a full autopsy will generally be indicated. In most cases, blood and other body fluids or tissues will be drawn at the time of examination for submission to the toxicology laboratory at the discretion of the forensic pathologist. Trace evidence will be collected from the body as appropriate during the examination, and clothing and other salient materials will be preserved for evidentiary purposes as needed. Photographs of injuries and of the decedent for identification and documentation purposes will also be obtained. The degree to which autopsy technicians assist forensic pathologists will vary from office to office, depending on staffing, tradition, and local philosophy. In some offices, assistants may perform eviscerations of bodies under supervision of forensic pathologists, though the actual dissection of organs is almost always performed by the pathologist. In others, only pathologists eviscerate bodies. Either system is acceptable as long as all of these activities are under the direct supervision of a forensic pathologist. Assistants may also perform clerical duties, take radiographs, draw blood or other toxicology specimens, suture bodies closed, clean the body and examination area, assist in removal of clothing, and assist with inventory and preservation of clothing and evidence.

As a part of the medical or autopsy section, a modern medical examiner’s office will maintain relationships with expert consultants to assist the medical examiner in specialized areas. One of the most important and commonly utilized consultants is the forensic odontologist. A trained and certified dental practitioner provides invaluable aid in helping to establish identification of decedents by dental comparison and in the evaluation of bitemark evidence, which may be invaluable in linking an assailant to a homicide victim.

Anthropologists assist the pathologist in evaluation of skeletal remains, again, in an effort to establish identification by narrowing the age, race, and sex of the decedent. They may also assist in evaluating traumatic or other changes in the skeleton that may show acute or remote injury. Neuropathologists, pediatric pathologists, radiologists, and other medical specialists may provide valuable input into the investigation of specialized medical aspects of a case, and nonmedical specialists, such as engineers, electricians, entomologists, meteorologists, and geologists, may assist in the evaluation of the external or environmental factors in a death.

The toxicology section is integral to the function of any modern medical examiner’s office. Proper analysis of the blood and other body fluids is not only required to confirm cause of death in cases of apparent drug overdose, but is routinely performed in cases of deaths due to unknown causes, deaths due to trauma, and some deaths due to apparent natural disease. Information on intoxication is critical to adjudication of many traumatic deaths, and often drug intoxication is found in deaths initially thought to be solely due to natural disease. Tough many large medical examiners’ offices will have an on-site dedicated toxicology laboratory, other, smaller offices may find that it is more cost-effective to utilize the services of a large of-site commercial laboratory. In either case, it is imperative that the laboratory be appropriately accredited and supervised, and that protocols for specimen collection, retention, and analysis be well established and meet the requirements of the chief medical examiner or supervising forensic pathologist. It is also necessary that the forensic toxicologist be available for ready consultation in difficult or problematic cases.

The clerical section of the medical examiner’s office is responsible for providing a critical interface of the office with the public (reception), transcription of physician’s dictated reports, preparation of death certificates, coordination of court appearances, and maintenance of documents, records, and data. This section will also respond to subpoenas, public information queries, and the myriad other requests for information that are submitted to the medical examiner’s office each day.

In a medical examiner system, office administration must be under the auspices of the chief medical examiner. It is imperative that this individual have full authority over operational, budgetary, and personnel matters, though he or she may employ administrative, fiscal, and other assistants, and delegate duties to them as needed. It is the chief medical examiner who will determine the procedures and policies of the office, and final authority over the office must reside with him or her, as well as responsibility for the performance of all aspects of the office. This includes responsibility for all investigations and examinations, and for maintaining the quality of the office’s work products. Adequate civil service protection is optimal for all medical examiners, to help ensure that these physicians are not intimidated or punished for their honest professional opinions, which form the true work product of the organization.

Coroner systems will have many organizational facets in common with medical examiners’ offices, with the exception that final authority of the medical investigative agency does not reside with a trained physician (with the exception of rare cases in which the coroner is also a board-certified forensic pathologist). It is imperative, then, that the coroner’s chief forensic pathologist has adequate authority over all operational matters to ensure that good forensic pathology procedures are followed in all areas. This will require adequate input into budgetary and personnel matters, as well as medical matters.