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.     

Medical examiner/coroner records: uses and limitations in occupational injury epidemiologic research

Epidemiologic research often relies on existing data, collected for nonepidemiologic reasons, to support studies. Data are obtained from hospital records, police reports, labor reports, death certificates, or other sources. Medical examiner/coroner records are, however, not often used in epidemiologic studies. The National Institute for Occupational Safety and Health's Division of Safety Research has begun using these records in its research program on work-related trauma. Because medical examiners and coroners have the legal authority and responsibility to investigate all externally caused deaths, these records can be used in surveillance of these deaths. Another use of these records is to validate cases identified by other case ascertainment methods, such as death certificates. Using medical examiner/coroner records also allows rapid identification of work-related deaths without waiting several years for mortality data from state offices of vital statistics. Finally, the records are an invaluable data source since they contain detailed information on the nature of the injury, external cause of death, and results of toxicologic testing, which is often not available from other sources. This paper illustrates some of the ways that medical examiner/coroner records are a valuable source of information for epidemiologic studies and makes recommendations to improve their usefulness.     

Uncertainty of determining mode of death in medicolegal material without autopsy — A systematic autopsy study

Systematic autopsy was performed in 807 medicolegal deaths where the police had not requested autopsy. In all cases both the cause of death and the mode of death had been reported at the medicolegal external examination. The autopsy revealed differences in the mode of death in about 4% of all cases. This was due in particular to the problems associated with distinguishing presumed natural deaths from accidents and suicide. The cases of “concealed” suicide were found in particular among the higher age groups. However, no characteristic relationship was found between the proportion of differing modes of death and the age groups. All cases of homicide were recognized at the medicolegal external examination.Malignant disease that had not been diagnosed previously was found in about 4% of the cases, the reason being the large proportion of elderly subjects in the material. Syphilitic aortitis that had not been previously diagnosed was demonstrated in about 1% of all cases, and pulmonary tuberculosis that had not been previously diagnosed was demonstrated in 0.7% of the cases.The conclusion is that the results provide no support for replacing the medicolegal autopsy by medicolegal external examination alone, but rather suggest that the proportion of medicolegal autopsies should be increased.     

Level of agreement between opinions of medical examiner investigators and forensic pathologist medical examiners regarding the manner of death

To evaluate the level of agreement between medical examiner investigators' opinion of the manner of death and what the manner of death was as certified by forensic pathologist medical examiners (MEs), we reviewed the case records stored in a database of all deaths reported to the office of the medical examiner in Fulton County, Georgia. Of 15,771 deaths reported to the office during a 10-year period, a difference exists in 1908 cases. In 900 natural deaths, the investigators recorded 135 accident, 10 homicide, 10 suicide, and 745 undetermined manners of death. In 755 accidental deaths, the investigators recorded 16 natural, 8 homicide, 13 suicide, and 718 undetermined manners of death. In 107 homicides, the investigators recorded 12 natural, 8 accident, 0 suicide, and 87 undetermined manners of death. In 70 suicides, the investigators recorded 9 natural, 9 accident, 3 homicide, and 49 undetermined manners of death. In 61 deaths classified as undetermined, the investigators recorded 25 natural, 13 accident, 17 homicide, and 6 suicide manners of death. In 15 deaths, the discrepancy exists due to an apparent error in the database information. This study confirms a high concordance between investigator and ME opinion regarding manner of death but also documents the need for case review and autopsies by forensic pathologists to confirm the investigators' opinion of the manner of death, determine the manner of death when the investigator selects undetermined, and on occasion, refute the investigators' opinion regarding the manner of death.     

Utility of infectious disease coding sheets for surveillance in a state medical examiner's office

Medical examiners are often first to recognize unusual occurrences of fatal infectious diseases. Recognition of these deaths allows public health officials to institute appropriate public health measures. Therefore, we developed a simple method of identifying and tracking infectious disease deaths in a statewide medical examiner's office. One-page infectious disease forms were completed for 1566/1949 autopsies (80%) performed at the New Mexico Office of the Medical Investigator in 2004. In 241 cases one infectious disease was identified at autopsy and 58 cases had two infectious diseases. Fourteen of the infectious-diseases caused deaths involved diseases that are notifiable conditions in New Mexico. Pneumonia was the most commonly reported infectious process (47 deaths) followed by sepsis (25 deaths). Tracking infectious disease deaths highlighted the importance of recognizing these deaths, although hand-written entries were unstandardized. Preferably, a tracking system would be built into electronic databases at medical examiner and coroner's offices, expediting the identification of these diseases and contact of public health agencies.     

Fatal drug poisonings: medico-legal reports and mortality statistics

The entire fatal drug poisoning panorama in Finland is considered in terms of three catergories: accidental, self-inflicted and undetermined (whether accidental or with intent to harm) deaths. The study material consisted of all 500 deaths in 1997 that medical examiners, after examination(s) at the Forensic Toxicology Division (FTD) of the Department of Forensic Medicine, University of Helsinki, officially certified as resulting from drug poisoning. These deaths were matched with data on the same deaths registered at Statistics Finland (SF), the national mortality statistics office. The SF register included 72 additional instances of deaths resulting from drug poisoning. In all but two of these cases, the cause-of-death determination was based on a medico-legal inquest with autopsy and forensic toxicological examination(s) and was certified, in most of the cases, as due to the alcohol component in multiple-toxicant combinations. Reclassifying these deaths at SF to the category of drug component is in accordance with current International Classification of Diseases (ICD-10) regulation of coding "to the medicinal agent when combined with alcohol"; the principle and practice, which is recommended to be amended to equalize the status of alcohol and drug when explicitly stated by a forensic examiner as the principal toxicant in combined poisonings. With regard to manner-of-death, the agreement rates between medico-legally proven deaths from drug poisoning and those registered at SF were 79.8% for accidents, 98.5% for suicides and 0% (nil) for undetermined deaths, at the level of three-character external cause codes (E-code). All deaths originally certified as undetermined were re-assigned, most frequently to the category of accidental death. Since within an advanced and sophisticated medico-legal system, a medical examiner's evidence-based statement, even when the conclusion reached is undetermined (as to intent), should be taken as a compelling argument, the practice of reclassification cannot be considered advisable because assembled information is lost. Concerning the assigned drug-specific groups, the agreement according to the manner-of-death between certifications and registrations was fairly good. From among the accidents, however, opioid poisonings were re-assigned in 11 (29.7%) cases, mostly to the drug abuse/dependence categories, i.e. they were considered as natural deaths by the statistics office. The drug-specific observations were possible only by using the codes from the Anatomical Therapeutic Chemical (ATC) classification of drugs. This is why the incorporation of ATC codes into the ICD system, whenever reasonable, is recommended.     

The medical examiner and AIDS. Death certification, safety procedures, and future medicolegal issues

The current worldwide epidemic of AIDS will have profound consequences not only for the delivery of health care, but also for forensic pathologists and investigators. AIDS continues to spread in definable risk groups, and deaths within some of these groups may fall under the jurisdiction of the medical examiner. We outline an approach to handling AIDS deaths based upon case definition, diagnosis by available information and procedures, and proper infection control. We also discuss medicolegal issues surrounding deaths due to AIDS.     

Determination of cause and mode of death before and after medicolegal autopsy: a comparative study

Two hundred and twenty-eight consecutive medicolegal autopsies were studied as to the cause of death established by a physician, the mode of death as suggested in the police report, and findings of medical interest often discovered following autopsy. Corrections had to be made even in some cases which seemed to be obvious. With a decrease of the number of autopsies, the records of various registration bureaus would be affected. Autopsies are still necessary for control and correction of clinical causes of death.     

Tuberculosis and sudden death in Baghdad

Tuberculosis deaths represent a recognizable proportion of all medicolegal statistics in and around Baghdad. Out of the total number of autopsies performed at the Medicolegal Institute at Baghdad, Iraq, in the years, 1948, 1953, 1958, 1963, 1968, 1973, and 1978, 168 sudden deaths were attributed to tuberculosis. Bilateral pulmonary tuberculosis was the principle lesion in the majority of the victims. Tuberculosis cavitation was the major finding in 126 cases, followed by advanced pulmonary TB without cavitation in 25. There was no gross abnormality, except for a histological basis of pulmonary TB associated with miliary TB involving hepatic, renal, meningeal, and mesenteric organs in the remaining 17 autopsies. The abrupt and suspicious deaths in older people, especially during cold months, is more likely due to TB. Autopsy should be performed in all cases of sudden and suspicious deaths. Histological study of different body organs, whether death is attributed by the investigative authority or not related to TB, should be required in all medicolegal autopsies, in order to obtain a true picture of TB as a natural cause of death.     

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.     

Surveillance of human immunodeficiency virus (HIV) antibodies in medicolegal autopsies in Finland--monitoring early changes in HIV-seropositivity among risk groups and average population.

In order to cooperate with voluntary screening programs aimed at the surveillance of the HIV epidemic in Finland, we have studied medicolegal autopsies for HIV antibodies since 1986 using an enzyme immunoassay on postmortem sera. The investigation covered 47.4% and 39.2%, respectively, of all deaths under the age of 65 years in the metropolitan areas of Helsinki and Turku--two cities on the densely populated southern coast of Finland from which most HIV infections have thus far been detected. Nine HIV-positive cases (0.12%) were detected among the 7305 medicolegal autopsies tested in 1986 to 1990. This figure is higher than the prevalence of 0.01 to 0.03% in voluntary screening programs for the general population would suggest. Seven of our cases had previously tested positive, and two were previously unknown cases, indicating that people at high risk are clustered in the medicolegal autopsy series. Of the six cases in an early stage of infection, three committed suicide suggesting the importance of HIV-screening in suicide cases in tracing symptomless HIV carriers. Five of the cases were detected in 1990, a year when the number of new HIV infections had more than doubled compared to the previous two years. This suggests that testing of medicolegal autopsies as surrogate tests for the population gives useful information even in low-prevalence areas like Finland. Such testing has none of the ethical problems of many other back-up surveys, and may be particularly sensitive to early changes in epidemiology.     

Uncertainty of determining cause of death in a medicolegal material without autopsy. An autopsy study

In constrast to other studies, this investigation was made on cases of medicolegal deaths that would not normally be autopsied. 223 females and 322 males, whose deaths were found to be natural before as well as after autopsy, were studied. The cause of death was estimated by external medicolegal examination, and after autopsy.In 79 females and 109 males, i.e. 35% and 34% respectively, estimated cause of death was found to be different after the autopsy. This was mostly because ischaemic heart disease as a cause of death was overestimated at the external medicolegal examination. No constant relationship between differing causes of death and age group could be demonstrated. Underdiagnoses and overdiagnoses tended to outweigh each other. Pneumonia, pulmonary embolism, cor pulmonale and aortic stenosis were clearly underestimated before autopsy. In addition, a variety of diseases that were not even mentioned at the medicolegal examination was found (subarachnoid haemorrhage, uraemia, perforated and bleeding gastric ulcers, tuberculosis).The same unreliability in the estimated cause of death therefore exists among cases not normally autopsied as found in retrospective studies of cases where autopsy is performed under all circumstances at the request of the police.False information will thus be given to the mortality statistics among the approximately 5000 cases of medicolegal deaths not autopsied in Denmark per year, most of these being natural deaths. Besides, contagious and inherited diseases could be overlooked, relatives given false information and the value of scientific studies in causes of death diminished.The conclusion is that autopsy is still essential to ensure continuous control and correction of causes of death.     

Pathology of sudden death during recreational sports activity: an autopsy study of 31 cases

A growing number of people are involved in recreational physical activity. It is therefore not uncommon for a medical examiner to encounter sports-related sudden deaths and to be faced with the legal implications. The authors examined the clinical and cardiac pathologic patterns in 31 persons who died suddenly during sports activities and underwent autopsy at the Institute of Forensic Medicine of Paris between 1991 and 2001. Twenty-nine male subjects, ranging in age from 7 to 57 years (mean 30 years) and two female subjects, 8 and 60 years old, died suddenly during sports activities. The sports involved were various, with running the most frequent: 13 cases. Cardiomyopathies (10 cases) and coronary artery disease (9 cases) were the most frequent causes of deaths. Despite the severity of lesions, only 4 subjects had a known cardiovascular disease. In conclusion, with regard to prevention, efforts should be continued to improve the sensitivity and specificity of diagnostic tools and screening strategies. In this regard, medicolegal autopsies should be systematically performed in cases of sudden death during sports activities, because they provide accurate and useful information for a better knowledge of sports-related mortality.     

Causes of sudden natural death in Jamaica: a medicolegal (coroner's) autopsy study from the University Hospital of the West Indies

Medicolegal (coroner's) autopsies are an important source of epidemiological data. A large proportion of them comprise sudden natural deaths and an analysis of such cases has never been undertaken at the University Hospital of the West Indies, the only teaching hospital in Jamaica. In a retrospective study, 841 cases of sudden natural deaths comprising 51.3% of the medicolegal autopsies conducted over the 15-year period, January 1983 to December 1997, were analyzed. There were 459 males and 382 females (M:F ratio = 1.2:1); 35 patients (4.1%) were less than 1 year of age, and the mean age of the remainder was 53.7+/-21.8 years. The peak age group was the seventh decade accounting for 21.9% of cases. The most common causes of death were cerebrovascular accidents (13.6%), pneumonia (9.4%), pulmonary embolism (7.4%), ischaemic heart disease (7.0%) and diabetes mellitus (6.1%). These findings contrasted with those from developed countries in which ischaemic heart disease is the commonest cause of sudden death. Hypertension was associated with the majority of cases of cerebrovascular accident and congestive cardiac failure (78.1 and 61.9%, respectively). Sickle cell disease represented one of the 10 most common causes of death accounting for 2.5% of cases. Documentation of autopsy-based data such as these is important in the planning of medical services in a developing country.     

Exploitation of autopsy in determining natural cause of death: Trends in Finland with special reference to the diagnostics of ischemic heart diseases and cerebrovascular diseases in middle-aged males, 1974–1993

Finnish mortality statistics show a marked decrease in coronary disease mortality especially among middle-aged males during the last 20 to 25 years. At the same time, the overall autopsy rate in deaths due to natural, non-violent causes has diminished in Finland. National mortality statistics are based on medical information given in death certificates. How often are the causes of death based on autopsy and is there any definitive trend? Possible changes in cause-of-death determination practices may have contributed to the mortality changes observed. In this study, deaths due to ischemic heart diseases (IHD) and cerebrovascular diseases (CVD) from 1974 to 1993 in Finland were compared with natural deaths, i.e. all of the deaths due to natural causes, in regard to use of autopsy. It was found that IHD-diagnosis as the underlying cause-of-death was, unlike natural deaths and CVD in particular, increasingly based on autopsy. It is thus concluded that the recent decline in coronary disease mortality among middle-aged men in Finland cannot be explained by any deterioration in cause-of-death examination practices.     

Reye's syndrome. A diagnosis occasionally first made at medicolegal autopsy.

Reye's syndrome, a condition characterized pathologically by cerebral edema and fatty change of the liver, has been described extensively in the medical literature as a disease manifested clinically by encephalopathy and coma. This is a report of five cases of Reye's syndrome occurring as sudden, unexpected deaths outside of the hospital. In each of these cases, there is a vague history of a previous viral illness. A history of aspirin intake is inconstant. Each child either had no significant past illnesses or there was a history of repeated upper respiratory infections. The classic progression of signs and symptoms usually described for Reye's syndrome, where vomiting usually precedes encephalopathy and coma, was not present in any of the cases. Results of autopsies showed the characteristic findings for Reye's syndrome, and additional tests showed no other explanation for the deaths. This manifestation of the disease is seldom described in medical literature, but it may be encountered occasionally by the medical examiner.     

Heat-related mortality in selected United States cities, summer 1999.

As part of a public health response to severe heat waves in the midwestern and northeastern United States in the summer of 1999, the authors actively solicited the number of heat-related deaths from 38 medical examiner and coroner jurisdictions comprising 35 metropolitan areas to enumerate heat-related deaths in areas affected by heat waves. They also determined the usefulness of these data for surveillance and rapid investigation of heat-related deaths. A total of 334 heat-related deaths were reported during the study period of July 1 - August 31. Minor changes in data collection and diagnostic criteria in some medical examiner and coroner jurisdictions would allow for greater comparability among jurisdictions. The National Association of Medical Examiners' position paper on heat-related mortality diagnosis provides important guidance to medical examiners and coroners regarding the certification of heat-related deaths and may require some refinement to address certain issues. Among these are certifying manner of death and classifying potential causes of heat-related death not involving hyperthermia or heat stroke, but where heat is a potential contributing factor to death. Medical examiners and coroners are an important resource for heat-related mortality research, and improvements in data collection and reporting could yield tremendous benefits to our understanding of and interventions for heat-related deaths.     

An analysis of the medicolegal autopsies performed in Adana, Turkey, in 1983-1988.

Data on 1,000 medicolegal autopsies have been compiled by the Morgue Department of the Adana branch of the Council of Forensic Medicine of Turkey, and have been reviewed to determine the local differences in causes of death, as well as age and sex distributions of decedents, in medicolegal deaths in this region. This is the first report on this subject in this region of Turkey. Unusual categories of death and incidences of death are also discussed. The results of this study show that the number of medicolegal autopsies and the rate of natural death in Adana are quite close to those of some other cities of Turkey and some foreign countries. Contrary findings are revealed in the frequencies of the causes of death.     

Alcohol in a series of medico-legally autopsied deaths in northern Norway 1973-1992

It is well established that use of alcohol increases the risk of fatal injuries. The presence of blood alcohol in autopsied deaths is regularly encountered in medico-legal practices. The aim of this study was to investigate the prevalence and concentration of alcohol in 1539 medico-legal autopsies in two counties in northern Norway in the period 1973-1992, and the reporting of acute alcohol influence among these deaths to the official cause-of-death statistics. Blood alcohol concentration (BAC) >/=0.5 per thousand (50 mg/100 ml) was found in 47.6% (n=456) of violent deaths tested, and in 93% (n=426) of these the BAC was >/=1.0 per thousand. In 17.4% (n=55) of tested natural deaths the BAC was >/=0.5 per thousand. Acute alcohol-influenced violent deaths were under-reported to the cause-of-death statistics. Deaths by motor vehicle traffic accidents did not differ from other violent deaths in this respect. The under-reporting among violent deaths was 41% in cases with BAC >/=0. 5 per thousand and 37% where the BAC was >/=1.0 per thousand during the whole period. It is concluded that post-mortem BAC >/=0.5 per thousand, should be regarded as a possible contributory cause in all violent deaths, and reported accordingly.     

Neoplastic disease in a medicolegal autopsy material. A retrospective study in northern Sweden

Only a small fraction of sudden unexpected deaths are caused by neoplastic disease and thus subject ot medicolegal autopsy. The medicolegal autopsy forms an opportunity to study not only medically diagnosed and treated neoplasms, but also the natural evolution of untreated disease. In a series of 7,020 consecutive medicolegal autopsies in northern Sweden, we found 171 cases with malignant and/or intracranial neoplasms. In 41 cases, sudden death was caused by previously unknown tumors. The most common mechanisms of death in this group were disseminated cancer, intracranial tumors, pulmonary thromboembolism, hemoptysis, and aspiration of blood, and the most common locations were the bronchi and the lung. In some of these cases, the mechanism was sometimes dramatic, raising a question of violent death or intoxication. In 30 cases, sudden unexpected death was caused by previously known tumors, and also in this group disseminated cancer was the most common cause of death, and the most common locations were the bronchi and the lung. In 22 cases, tumors were found suicidal cases; in 14 of these, the tumor was considered to be a major causative factor to the suicide, while in eight cases the tumor was considered to be an incidental finding. The expected number of cancers in the 1,060 suicides investigated in this series was 27, according to the official cancer prevalence data. Thus, a possible over-representation of suicides among persons with cancer seems doubtful and needs further exploration.