Academic Forensic Pathology

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.

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.

State death investigation laws were reviewed to determine which duties coroners have that go beyond death investigation and are not typical duties of medical examiners. Twenty-four states have statutes giving coroners one or more other such duties. Those duties include acting as the sheriff and/or being in charge of the jail when the sheriff is unavailable, serving as public administrator, providing ambulance services, supervising the sanitary conditions at penal institutions, performing clinical rape examinations and mental commitments, attending judicial executions, filling in as a county commissioner, and operating small claims courts and issuing warrants. Colleagues in many states reported that these statutory duties have actually been performed, although rarely. If a state or local jurisdiction were considering transition from a coroner system to a medical examiner system, any legislative change would need to consider whether the medical examiner would assume all duties of the coroner, or whether other solutions would be needed to carry out the tasks that are not related to death investigation. Legislation to change from coroner to medical examiner systems would need to ensure that any such essential services unrelated to death investigation are transitioned to other officials.

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.

Based on a one-month online survey that was announced to 640 subscribers of the National Association of Medical Examiners’ NAME-L listserv, perceived strengths, limitations, and needs of death investigations systems were obtained for the 25 states that lack a state medical examiner. Forty-one persons responded to the survey and at least one response was obtained from each of the 25 states. Overall, strengths could be summarized into categories that include the local nature of death investigation (e.g., items related to coroners, medical examiners, forensic pathologists, and accreditation and certification) and issues related to finances, organization, and system oversight. Perceived limitations fell into similar general categories but the largest group of comments consisted of coroner-related concerns. Needs could be categorized into issues which relate to facilities and death investigation system features; finances; coroners, forensic pathologists, and accreditation and certification; standards, training, and education; and research and technology. Specific strengths, limitations, and perceived needs are summarized in tables showing the states citing those features. We hope these data will be useful to those who wish to further study death investigation systems in the various states.

Having served as a board-certified forensic pathologist in the southern tier of New York for over 23 years, the author has received cases from over a dozen rural New York State coroner counties. While some coroners are physicians, none of them is a pathologist, and most are not in the medical profession. Some are appointed by their county legislature, whereas others are elected. Levels of coroner training and experience in death investigation, terms of office, multiple coroners per county, and turnover of coroner staff are all challenges for the consultant forensic pathologist. Functioning as an autonomous independent contractor, a forensic pathologist can bring standardization, medical knowledge, and reliability to the determination of cause, mechanism, and manner of death, even when resources are less than optimal. As fewer hospital pathologists perform autopsies, and as community hospitals opt to close their morgues entirely, regional centers emerge to absorb the workload. In such a setting, the forensic pathologist must establish a working relationship with an institution such as a regional hospital to support an adequate physical plant for an autopsy service. Until such time as adequate manpower and financial resources are available, a coroner-based death investigation system is still a necessary complement to the medical examiner system in New York State. There are both drawbacks and advantages to such a practice for the independent forensic pathologist. Yet the citizens of this area of New York State are served by a death investigation system that is functional and meets basic needs.

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.

Michigan has experienced a surge in the appointment of board-certified forensic pathologists as the County Medical Examiner, seeing an increase from eight counties with slightly less than 50% of the state's population in 1999 to 20 counties with 75% of the state's population in 2013. This article examines this positive change in Michigan, provides information that may explain this trend, and describes the competitive process that many counties are using to identify and appoint their County Medical Examiners. There is competition among forensic pathologists not only for County Medical Examiner positions, but for fee-for-service forensic pathology services as well. Virtually all counties in Lower Michigan and some counties in the Upper Peninsula have autopsy services provided by the 17 board-certified forensic pathologists who live and work in Michigan, and five additional forensic pathologists who live and work in nearby states. Statutory changes have created the opportunity for competition (turf battles) among individual forensic pathologists or practice groups of forensic pathologists. Such competition can have positive effects, but can also have negative impacts such as reduced stability in a county's death investigation system or even job security for forensic pathologists. The emerging trend in Michigan is one of forensic pathology operations of board-certified forensic pathologists (BCFP) serving regions of counties within the state.

The death investigation system for the state of South Carolina is a coroner system. The state has 46 counties and each has one elected lay coroner. The educational requirement is a high school diploma. Many physicians and legislators have repeatedly attempted to change the state and large counties’ death investigation systems to medical examiner systems. Due to the politically strong coroners, these attempts have been largely unsuccessful. In 1972, Charleston County converted to a medical examiner/coroner dual system. This system was constantly challenged until it reverted back to a coroner system in 2001. The establishment of the dual system, hurdles and road blocks confronted, and reasons for the ultimate reversion are discussed.

In the first part of the 20th century, Native American tribal reservations were allowed to become self-governing, semiautonomous sovereign nations. Although these tribal governments have the authority to establish their own death investigation systems, in South Dakota, the tribes have largely ceded this authority to the county coroners. The county coroner role at unattended deaths in Indian Country has been largely taken over by law enforcement (the Federal Bureau of Investigation and/or the Bureau of Indian Affairs), leaving the county coroner with limited duties other than signing death certificates. The majority of autopsies ordered on unattended tribal area deaths are procured by law enforcement, in part since law enforcement is the only agency with sufficient funds to pay for autopsies.

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.

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.

This article describes the transition of the Oregon State Medical Examiner from public health agency oversight to an entity that is now administratively within the Oregon State Police (OSP), along with relevant office history. Data are drawn from personal experience and statutes. There are those that feel it is a conflict of interest to operate a medical examiner (ME) program as part of a police agency. The majority of any medical examiner cases are medical problems, not criminal issues. Forensic pathologist medical examiners are trained to tell the difference. OSP has supported the ME program infinitely more in every way than the prior public health agency. To date, no conflict or pressure has been brought to change or influence the conduct of a death investigation and the issue has never been raised in the courtroom. The ME program was poorly understood, underfunded, understaffed, and on the verge of collapse under the health department administration, but continues to thrive and improve under the Oregon State Police. Other medical examiner systems with lack of funding and support may wish to consider the Oregon experience.

Forensic Pathology was recognized as a subspecialty by the Royal College of Physicians and Surgeons of Canada (Royal College, formerly RCPSC) in 2003. In 2008, following a series of recommendations made by a government inquiry into systemic failures in the provision of pediatric forensic pathology service in Ontario, there was impetus for the Royal College's Forensic Pathology Specialty Committee to develop standards of training, assess proposed residency programs, and establish a certification mechanism for pathologists practicing forensic pathology in Canada.

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.

Deaths due to internal obstructions of the airway (choking) are preventable injuries that are often associated with underlying risk factors including neurologic impairment by disease, intoxication, or very young or old age.

We reviewed 138 decedents with accidental internal obstruction of the airway. Records including autopsy, toxicology, and investigators’ reports were reviewed for a five-year period. There were 138 choking deaths and the age ranged from one to 96 years (mean = 57). Neurologic disease (e.g., remote cerebral vascular events, dementia, developmental disorders) was the most common risk factor for fatal choking (51%), followed by acute alcohol intoxication (13%), psychiatric illness (8%), and young age (8%). In 8% of decedents, there was no identifiable risk factor following investigation, autopsy, and toxicological examinations. The choking episode most commonly occurred in residences (62%), followed by nursing home/long-term care facilities (20%), streets/parks (6%), restaurants/bars (4%), and schools (1%, including one culinary school). Meat was the most commonly identified food object (14%); non-food objects included drug packets.

It is exceedingly rare for a neurologically intact adult to choke to death on a bolus of food without another underlying, identifiable risk factor. For death investigation, it is important to have a high index of suspicion for choking, and one must be careful not to confuse terminal aspiration of gastric contents with a fatal blockage of the airway by a swallowed bolus of food. A risk factor should be sought in each choking death, as it usually is the underlying cause of death.

The pediatric skeletal examination (PSE) is an autopsy technique recommended for pediatric cases suspicious for nonaccidental injury. The technique requires the reflection of the musculature and periosteum of the ribs, clavicles, long bones, and scapulae, and inspection of the bone surfaces and chondro-osseous interfaces. The technique is time consuming, labor intensive and possibly disfiguring. Therefore, the value of the technique must be measured against the cost.

The present study was designed to evaluate the impact of the PSE on the sensitivity of the autopsy. A non-randomized retrospective review of 94 autopsy reports was done. The cause and manner of death for each case was classified as blunt force trauma and homicide. Half of the sample received a PSE during the autopsy and half did not.

The number of rib and long bone fractures noted in the reports was significantly greater in the group that received the PSE. The number of cranial, scapular and clavicular fractures was not significantly different between the two groups. The PSE does not increase the visibility of the neurocranium; therefore, a difference in the number of cranial fractures was not expected. Scapular and clavicular fractures were rare in the study population. The insignificant difference between the two groups may be a reflection of the rarity of the fracture as opposed to the sensitivity of the PSE. The results of the study indicate that the PSE increases the sensitivity of the pediatric autopsy with respect to long bone and rib fractures.

Cuyahoga County, Ohio has recently seen a dramatic rise in the number of deaths associated with heroin (DAH). DAH rose from 40 in 2007 to 161 in 2012 with heroin now identified in half of all overdose deaths. One third of DAH involve heroin alone; the remainder, in combination with other drugs. Over this period, opioid pain reliever (OPR) deaths appear to have plateaued.

Along with this rise have been shifts in overdose victim demographics. These data most notably include a rise in the number of women (from 15% to 24%), overdoses between the ages 19 and 29 (8% to 25%), and a generally equal number of urban and suburban fatalities.

The Medical Examiner's Office conducted a retrospective analysis of 2012 fatalities to identify potential risk factors and intervention points. This review indicates that most victims (81%) were known to abuse drugs. Half were found with drug paraphernalia at the scene. Approximately 12% were using heroin with other addicts, while 60% were using drugs or succumbed to them in proximity to other non-using people. Emergency medical services were only able to administer naloxone in 22% of cases. Histories of recent abstinence (29%), incarceration (18%), and detoxification (31%) were noted and may reflect times of increased risk secondary to decreased tolerance. A prescription for legal controlled substances was noted in 64% of DAH (the most common medications being OPRs and benzodiazepines). This suggests a need to address prescribing practices. Public health interventions, implemented or planned, based on these data are discussed.

A number of articles and technical notes describing various methods of softening or casting mummified fingers to obtain fingerprints have been published in the scientific literature over the last 50 years. The publications to date describe either single case reports or a small number of cases in which mummified fingers were rehydrated or casted using a variety of techniques. From 2001–2012, we rehydrated approximately 425 pairs of mummified hands for fingerprint identification using a 3% sodium hydroxide (NaOH) solution. Disarticulated mummified hands are rehydrated in a 3% NaOH solution for 48–72 hours until the desired level of suppleness is reached. Following rehydration, the hands are dried and fingerprinted. From 2011–2012, 76 pairs of mummified hands were rehydrated using this technique. Positive fingerprint identifications were made in 34 (45%) of the 76 cases after successful rehydration.

Idiopathic spontaneous intraperitoneal hemorrhage (ISIH), or abdominal apoplexy, is due to nontraumatic, small vessel rupture; excluded by definition is hemorrhage associated with aortic aneurysm, gynecologic conditions (including ruptured ectopic pregnancy), and bleeding tumors. As defined, this condition is rare and etiologically complex. We report a case of ISIH associated with ruptured dissection of the gastroduodenal artery (GDA) which occurred following two paracentesis procedures for ascites due to cirrhosis. Severe acute inflammation of the vessel wall and resolving endocardial thrombosis suggest an infectious or “mycotic” etiology for this arterial dissection. Direct vascular injury during paracentesis was excluded as a cause of death. Small artery hemorrhage may be associated with aneurysmal rupture or other vasculopathies. Visceral small vessel aneurysms are rare, and GDA aneurysms are even less common. Although the regional vascular anatomy is complex and finding a bleeding point within a bloody field with no intravascular pressure may be impossible, careful dissection of the smaller vascular branches can be rewarding. Clinical management of ISIH is also challenging since findings may be nonspecific and limited to hemodynamic instability and atypical abdominal pain; however, immediate exploratory surgery is the treatment of choice, and the non-operative mortality approaches 100%.