Investigation of elderly deaths in nursing homes by the medical examiner over a year

Despite death being one of the most common reasons for discharge from a nursing home, fewer than 1% of nursing home resident deaths are autopsied. To evaluate our role as medical examiner in nursing home deaths, we conducted a retrospective review of all decedents in Jefferson County, Alabama, for the year 2001. Death certificate data indicate that 995 deaths occurred in nursing homes in Jefferson County in 2001. Of those 995 deaths, 119 (12%) were reported to the Jefferson County Coroner/Medical Examiner Office. Jurisdiction was accepted in 5 cases in which the circumstances already made clear that the death was a nonnatural event. In the remaining 96% of nursing home deaths reported to the medical examiner, the statements of the reporting person were taken to be true concerning the expected nature of the death. An independent scene evaluation was provided by a police officer or paramedic in 82% of the cases reported to the medical examiner's office. Elderly individuals, as a group, are expected to die, but the death of a particular elder may or may not be expected. In our jurisdiction, only 12% of all nursing home deaths are reported to our office, and only 4% of reported deaths are actively investigated. Actively investigating each nursing home death would overwhelm the resources currently available to our office. We advocate the study and development of criteria to aid in determining whether the death of an individual elder is sudden and unexpected.     

Unnatural death investigation in India. A plea for the introduction of a medical examiner system of inquest

The inquest upon a dead body is the basis of the scientific crime investigation and administration of criminal justice. The pivotal issue in any inquest is the initial visualization of the body and its surroundings at the scene of incident by a team of investigators and experts. This must be carried out meticulously, since the subsequent course of the case, and its success or failure in the court of justice, essentially depends upon its proper execution. Unfortunately, such an important step as the inquest is generally the most neglected part of any crime investigation process as it exists in India today. It is quite often left entirely to the inspired guesswork and seasoned experience of the lowest ranking police officers and more often than not to a Head Constable of a police station or substation. Nevertheless, while the coroner's system has proved to be utterly unsuitable for Indian conditions, we have failed to find an alternative solution to the growing challenge of scientific crime investigation in India, by involving the forensic pathologist in inquests held upon dead bodies, by including him in the first crime investigation. A strong case is made for adoption of the medical examiner's system of inquest, wherein the forensic pathologist plays the pivotal role and leads the "unnatural death investigation team."     

Recent Iowa trends in sudden unexpected infant deaths: the importance of public health collaboration with medical examiners' offices

During the winter in 2008, Iowa experienced an increase in sudden unexplained infant deaths (SUIDs). SUIDs and infectious causes of infant deaths generally average 3 monthly (SD = 1.0) in Iowa. However, in January 2008, 9 infant deaths were reported to the Iowa Department of Public Health and the Iowa Office of the State Medical Examiner. Between January and March of 2008, joint investigation of 22 SUIDs was conducted. The investigations required the involvement of multiple medical examiners from various jurisdictions, testing for pathogens at the University Hygienic Laboratory, epidemiologic support from the Iowa Department of Public Health, and consultation with the Centers for Disease Control and Prevention. The preliminary hypotheses for the increase in the infant mortality included viral respiratory disease and/or possible novel respiratory viral infections being the cause. Collaboration between public health and the medical examiner offices resulted in timely assessment of the cases. While no single causative agent was responsible for the increase seen in the number of infant deaths, respiratory pathogens played a role in the deaths of 15 of 22 children.     

Nonhuman remains and relics encountered by the medical examiner: Fulton County, Georgia, 2003-2004

BACKGROUND: Medical examiner and coroner offices occasionally respond to "death scenes" which, after investigation, are found to involve nonhuman remains or other relics not requiring further investigation or certification of death. This report describes such cases encountered by the Fulton County medical examiner during 2003 and 2004. METHODS: The electronic database used by the office contains check boxes to indicate whether a reported case involved nonhuman remains or other relics, in which case the name of the "deceased" is listed as "nonhuman remains" by selecting those words from a pull-down menu. Subject cases were identified during the 2-year period by searching the database for any case in which one of the boxes was checked or in which the name of the deceased was listed as nonhuman. RESULTS: Four thousand five hundred fifty-four deaths were investigated during the 2-year period, and 23 cases (0.5%) involved nonhuman remains or relics. Thus, the observed rate was about 5 cases per 1000 death investigations. Nineteen cases involved nonhuman bones. One case involved 2 human fetuses that had been teaching specimens. The other 3 cases involved a nonhuman fetus, a large decomposing dog that had been wrapped and dumped in residential area, and a sheep heart found in a bag which was a medical teaching specimen. CONCLUSIONS: Nonhuman remains and other relics are uncommonly seen in death investigation work and usually involve nonhuman bones, although a small variety of other atypical cases present themselves occasionally. Knowledge of these types of encounters is helpful so that the "unexpected" may become more "expected" and office policy and procedures tailored accordingly to facilitate case management.     

Pseudo-subarachnoid hemorrhage of the head diagnosed by computerized axial tomography: a postmortem study of ten medical examiner cases

In this report, we describe ten cases of pseudo-subarachnoid hemorrhage on computer axial tomography (CT) scan of the head. A pseudo-subarachnoid hemorrhage is a false positive finding by CT of the head in which the scan is interpreted as being positive for a subarachnoid hemorrhage not substantiated by subsequent neuropathologic findings. This study is a retrospective review of postmortem cases brought into the Office of the Chief Medical Examiner for the State of Maryland over a three-year period (from 1997 to 2000). We compared the clinician's impression of the CT scan with the postmortem neuropathology. The clinical diagnosis of subarachnoid hemorrhage was based on misinterpretation of non-contrast CT scans of the head. In six of the ten cases, the reading was performed by a radiologist and in four cases by nonradiologist physicians (emergency room physician, neurologist, or neurosurgeon). All the patients survived between a few hours to a few days after being admitted to the hospital. For most of the cases (80%), the neuropathology showed hypoxic/ischemic encephalopathy. The most common cause of death (four out of ten cases) was narcotic intoxication. This report is submitted so that clinicians and pathologist become more familiar with this entity.     

Paths toward reclamation: therapeutic jurisprudence and the regulation of medical practitioners

Much about what used to be termed "disciplinary" investigations and hearings is being revisited in the modern era. Therapeutic jurisprudence enables informed and sensitive awareness to potentially therapeutic and counter-therapeutic effects of both investigations and hearings conducted by medical regulatory authorities. This article analyses key aspects of authorities' processes from the perspective of notifiers/complainants and practitioners. Using developments at the Victorian Medical Practitioners Board as a base, it addresses issues of both investigative procedures and decision-making at formal and informal hearings, as well as the ramifications of re-hearings for the integrity of peer review informed regulation. It argues that where reclamation of practitioners is possible (namely where impropriety is not of the most serious order), there is much that is constructive about a focus upon enhancement of performance and competence levels, rather than the traditional preoccupation with whether registered status needs to be affected as a result of practitioner conduct.     

HealthConnect and the duty of care: a dilemma for medical practitioners

This article asks whether medical practitioners' duty of care to their patients will encompass participation in the HealthConnect shared electronic records initiative. Medico-legal aspects of the HeathConnect scheme relating to the nature of shared electronic health record summaries (SEHRS) are examined, focusing on their function as an element of patient care and their ultimate purpose. The analysis is based on the premise that an incomplete and hence inaccurate shared electronic health record summary is clinically and legally more perilous than no record at all.     

The conversion of coroner systems to medical examiner systems in the United States: a lull in the action

Coroner and medical examiner systems in the United States conduct death investigations for most deaths that are sudden and unexplained, or which involve external causes such as injury and poisoning. They play a very important role in the criminal justice, public health, public safety, and medical communities, and they also contribute a substantial portion of autopsy-based mortality data to the state and federal mortality statistics systems. Death investigations often involve complex medical issues and necessarily require the involvement of appropriately trained physicians. Over the years, there has been a trend to replace the elected lay coroner systems with systems run by appointed, physician medical examiners. Presently, about 31% of counties in the United States are served by a medical examiners at the county, district, or state level. Between 1960 and 1989, there was considerable conversion to medical examiner systems, but this trend slowed in the 1990s. Since 2000, only 6 counties in the United States have converted to a medical examiner system, no states have converted since 1996, and 1 county has reverted to a sheriff-coroner system. Possible reasons for this decline are discussed, including legislative, political, geographical, financial, population-based, and physician manpower distribution factors. It is important to ensure that all death investigation systems have appropriate access to medically educated and trained physicians such as forensic pathologists.     

Natural death as viewed by the medical examiner: a review of 1000 consecutive autopsies of individuals dying of natural disease

A study of 1000 consecutive autopsies of individuals dying of natural disease was conducted. Cardiovascular disease was responsible for 60.9% of all deaths with coronary artery disease--not only the main cause of cardiovascular death but also the main cause of all natural deaths--accounting for 45.1% of such cases. Diseases of the central nervous and respiratory systems accounted for 8.7 and 8.6%, respectively, of the natural deaths. Seizure disorders and pneumonia were the main causes of death in these organ systems. There were 124 deaths of children less than one year in age, 91 of which were due to sudden infant death syndrome (SIDS). All of the SIDS deaths were in children less than 10 months old.     

Forensic medicine in Great Britain. II. The origins of the British medicolegal system and some historic cases

The British medicolegal system, which today is largely based on the Coroner's Act of 1887, developed slowly, beginning with the election of county coroners in the 12th century. The duties of the medieval coroner included the collection of revenues due to the Crown, recordkeeping, presiding over inquests, and overseeing juries in cases of sudden or unnatural death. However, by the 14th century, the influence of the coroner had diminished and the office fell into disrepute. The practice of forensic medicine in the United Kingdom can be dated from the 17th century, when the first autopsy was recorded. However, the first original textbook on this subject did not appear in Britain until the early 19th century. Around the same time, due to a wave of homicidal poisonings, toxicology emerged as an important discipline. A number of historical cases of homicidal poisoning, as well as several cases of homicide by external wounding, are discussed herein. In the present day, with the passage of various laws, the British coroner deals only with sudden and unnatural death and treasure trove.     

Identifying the dead: methods utilized by the Pima County (Arizona) office of the medical examiner for undocumented border crossers: 2001-2006

The Pima County (Arizona) Office of the Medical Examiner has seen a dramatic rise over the past 6 years in the number of deaths related to the illegal crossing of our international border with Mexico. This rise in deaths is undoubtedly related to an increase in the number of foreign nationals who cross into the various Arizona jurisdictions that utilize the Pima County Medical Examiner to investigate their unnatural deaths. Because of the utterly dangerous nature of trekking across the Sonoran Desert, especially in the summer months, many of these unfortunate migrants succumb to the effects of heat-related illness and perish along the journey. The combined effects of a dry, hot environment and the remoteness of some of the trekking corridors can quickly render a deceased person unidentifiable by visual means. Thus, our office is faced with not only an increase in the number of deaths requiring medico-legal investigation but also an increase in the number of decedents needing additional specialized examinations in an effort to effect identification. This paper attempts to outline the problems and the methods utilized by our office over the past 6 years in the identification process of undocumented border crossers. It is hoped that this paper, as well as the others presented at this symposium, will allow for the sharing of information amongst all medical investigators who assist in the identification of these migrants. The identification of these individuals takes on added importance when one considers the possible nationalities, and perhaps motivation for entering into the US, of those that remain unidentified.     

Recovery of decomposed and skeletal human remains in the "Green River Murder" Investigation. Implications for medical examiner/coroner and police

The Green River Murder Investigation in King County, Washington, is currently the longest active serial murder investigation in U.S. history. During its course, over 26 separate scenes with from one to five victims each have been processed. The experience of the authors is presented in order to acquaint other agencies with techniques of outdoor scene processing that have evolved during recovery of remains from Green River and other skeletal cases.     

Malaria deaths in the United States: case report and review of deaths, 1979-1998

Malaria is the world's most important parasitic disease, accounting for an estimated 300 to 500 million new cases and between 1.5 and 2.7 deaths annually. The majority of these deaths occur in sub-Saharan Africa where malaria is endemic and are the result of infection with Plasmodium falciparum. The number of deaths in the United States due to malaria is comparably much lower and involves so-called "imported" cases in which U.S. travelers acquire the infection upon travel to endemic areas and subsequently return to the United States or in which infected foreign citizens travel to the United States. There were a total of 118 deaths due to malaria in the United States between 1979 and 1998 with an average of 5.9 deaths per year. Specific epidemiological data provided by the CDC regarding the 40 deaths that occurred between 1992 and 1998 yielded the following results. Deaths occurred in patients ranging from 9 months to 89 years of age (median, 53 years). Thirty-eight (95%) of these were due to P. falciparum and two (5%) due to P. vivax. Anti-malarial chemoprophylaxis was taken in 40% of cases, not taken in 45% of cases, and unknown in 15% of cases. Twenty-four (60%) of the cases involved U.S. travelers to endemic areas, of whom 59% traveled to Africa, 25% to South America, 8% to India, 4% to Haiti, and 4% to unspecified areas. The remaining cases included eleven foreign travelers to the U.S. (27.5%), three induced cases (7.5%), and two undetermined cases (5%). Thirty-nine (98%) of the cases were diagnosed antemortem and only one case was known to have come to the attention of the medical examiner/coroner. An illustrative case report demonstrates many of the features associated with fatal malaria infections in the United States. The case involves a U.S. student who was studying in Africa and who, by report, had not taken antimalarial chemoprophylaxis. Despite seeking medical attention, the patient was not diagnosed with P. falciparum infection and cerebral malaria until the time of medico-legal autopsy, where the classic gross and microscopic features of cerebral malaria were identified. This case represents one of the few cases of P. falciparum infection in the United States not diagnosed antemortem. Given the worldwide prevalence of the disease, increasing international travel, and rapidly developing drug resistance, malaria will continue to be an important disease and should be considered in cases of sudden, unexplained deaths. By reviewing the major epidemiological features of malaria-related deaths in the United States and by presenting the major gross and microscopic features of cerebral malaria, an attempt is made at raising the awareness of the forensic community to the potential of malaria-related deaths.     

Competition policy: consequences of restrictive trade practices and price-fixing provisions for medical practitioners in Australia and New Zealand

Competition laws have only applied to many participants in the health care industry in Australia and New Zealand since the mid 1990s. Since then, the Australian Competition and Consumer Commission has considered a number of applications by medical practitioner associations and private hospitals to authorise potentially anti-competitive conduct, while the New Zealand Commerce Commission has successfully prosecuted a group of ophthalmologists. Amongst medical practitioners, however, there is still confusion and misunderstanding concerning the type of conduct caught by the Australian Trade Practices Act 1974 (Cth) and the New Zealand Commerce Act 1986 (NZ). This is of serious concern given the substantial penalties associated with price-fixing and restrictive trade practices. This article examines the provisions of these Acts most relevant to medical practitioners as well as a number of determinations and judicial decisions. To provide practical assistance to medical practitioners, the key lessons are extracted.     

Validities and abilities in criminal profiling: a critique of the studies conducted by Richard Kocsis and his colleagues

In a recent issue of this journal, Kocsis reviewed the criminal profiling research that he and his colleagues have conducted during the past 4 years. Their research examines the correlates of profile accuracy with respect to the skills of the individual constructing the profile, and it has led Kocsis to draw conclusions that are important to the profiling field. In this article, the authors review the contributions of the Kocsis studies and critique their methodological and conceptual foundations. The authors raise a number of concerns and argue that data from the Kocsis studies fail to support many of the conclusions presented in his recent review. The authors present evidence in support of their assertions and provide recommendations that will allow future research in the area to generate data that are more meaningful and generalizable.     

日本近年来的刑事实体立法动向及其评价

日本从上个世纪90年代中期以来,为了应对犯罪的国际化、有组织化以及所谓“危险社会”中危险无时不在、无地不在的特点,强调对犯罪被害人的保护,顺应严惩暴力犯罪的国民呼声,一反战后日本刑事立法中所坚持的“非犯罪化和轻刑化”的倾向,在刑事立法上开始走向“犯罪化和重刑化”。另外,日本政府在2004年制定了“建立抑制犯罪社会的行动计划”。该行动计划中提出“完善有关凶恶犯罪的处罚原则,包括提高凶恶犯罪的法定刑的上限,将现在的有期徒刑的20年的上限再提高”的要求。对于这些刑事立法活动,学界表现出赞成和反对的对立看法。日本近年来的刑事立法活动中的上述倾向,实际上是日本战后刑法领域中所存在的两种基本理念的较量中,传统理念占了上风的体现。     

The "new" genetics: emerging medicolegal issues in the prenatal issues in the prenatal diagnosis of hereditary disorders.

Major advances in prenatal genetic diagnosis have occurred in the past few years which pose difficult challenges to the law. This paper raises questions relative to family history taking, genetic counseling, carrier detection, amniocentesis, and prenatal genetic studies, and also raises questions with respect to the rights and responsibilities of the patient, the fetus, the physician, and society in light of such modern advances. Law reform often occurs only after prior harm to an individual, family or group. Perception and delineation of the most important issues in this area should serve to stimulate the development of medicolegal guidelines and corrective legislation prior to the occurrence of a genetic tragedy.     

Heat stroke deaths caused by electric blankets: case report and review of the literature

Heat stroke is the most serious and potentially life-threatening condition of the heat-related illnesses. Heat stroke deaths caused by electric blanket are rarely reported. In this paper, we report 2 cases of fatal heat stroke caused by overheating from electric blankets in winter. One was a 41-year-old man who was found unresponsive in bed on an electric blanket. His wife shared the same bed with him and was found unconscious. The wife's axillary temperature was 40 degrees C (104 degrees C) when she was admitted to the hospital. She fully recovered after medical treatment. The husband was pronounced dead at scene, with rectal temperature at 41.2 degrees C (106.2 degrees C). The other was a 13-year-old girl who was found dead in bed on an electric blanket, with rectal temperature at 41 degrees C (105.8 degrees F). The literature is reviewed, and the pertinent findings, including scene investigations, postmortem examination, the risk and mechanism of fatal heat stroke caused by using electric blanket, are discussed.