Identification of the unidentified deceased: turnaround times, methods, and demographics in Fulton County, Georgia

CONTEXT: Multiple methods may be employed in an attempt to identify deceased individuals who are unidentified when reported to the medical examiner or coroner. The success and turnaround times of various methods differ. OBJECTIVE: To determine the number of deaths initially involving unidentified individuals, their demographics, the methods used and turnaround times for cases in which identification was successful and the portion of cases that remain unidentified for significant periods of time. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case review of all decedents who were initially unidentified when death was reported to the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between May 2003 and May 2004. MAIN OUTCOME MEASURES: Rate per 1000 deaths which involved an unidentified decedent, tabulation of methods used to make identifications, and rate of cases remaining unidentified. RESULTS: Of 2279 deaths reported to the office, 100 were originally unidentified, resulting in a rate of 44 unidentified decedents per 1000 deaths reported. Those who remained unidentified involved 6 cases, resulting in a "cold case" rate of 2.6 per 1000 deaths. Seventy-eight percent were identified within 2 days, and the most common successful methods were visual identification (52%) and fingerprints (31%). Dental (10%), x-ray (4%), and other methods (6%) were least commonly used. Of the 94 persons identified, all identifications occurred within 29 days. DNA procedures were not needed in most cases, and in the few cases where such tests were needed, results were either unavailable or failed to show a match with known samples. CONCLUSIONS: The majority of unidentified deceased individuals were identified within 2 days, with visual verification or fingerprints accounting for about 83% of methods successfully employed. The medical examiner noted a rate of 44 unidentified deceased persons per 1000 death reports, with an ultimate "cold case" (long-term unidentified) rate of about 2.6 cases per 1000 death reports. These data may be useful in developing office policy and procedure regarding the procedural and temporal aspects of investigations centered on achieving identification and making dispositions of unidentified deceased bodies.     

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.     

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.     

Applications of Social Network Media in Medicolegal Death Investigation

With the increased popularity of online social networking services (SNS) such as Facebook, LinkedIn, Twitter, and Google+, we propose that a wealth of new resources is available for medicolegal death investigation. Recognizing this potential, we identified cases in which social media had been useful in the past in our office and asked our investigative staff to consider using social media in current cases. These cases provided illustrative examples for this primer regarding how information from SNS was used in death investigations in our office. Information gleaned from online social media aided in establishing preliminary identification of a decedent, locating next‐of‐kin, investigating the circumstances of death as relevant to the manner of death, corroborating eyewitness accounts, and providing information relevant to time of death. Potential pitfalls were identified, such as shared accounts or online impostors. SNS proved useful to the medicolegal death investigator and medical examiner, so long as their limitations were recognized.     

Cadaver mix-up--an avoidable problem?

Depending on local conditions it may happen from time to time that no officer involved in the previous investigation is present during the forensic autopsy. In this case, the post mortem examiner often has to rely solely on written documentation concerning the identity of the deceased. The authors report a case where the body had already been mixed up with another body by the undertaker prior to the inspection by the police. In spite of clear distinguishing characteristics in the written documentation, this led to the wrong body being autopsied. For the post mortem examiner, the only safe way to identify a body seems to be the presence of persons who had known the deceased or of police officers as acknowledging witnesses. If these conditions are not given, other means of safe information on the identity are called for, for example a "police body card" similar to an evidence card.     

John and Jane Doe: the epidemiology of unidentified decedents

Abstract:  The number of people who cannot be identified at the time of death, sometimes referred to as John or Jane Does, is unknown, and little is known about them as a group. The study's objectives were to estimate the number of annual unidentified deaths, to identify demographic characteristics associated with dying unidentified, to determine whether the rates of such deaths vary geographically or over time, and to better characterize the causes of death. This was a population-based surveillance study of data collected from death certificates from 1979 to 2004 in the U.S. Subjects were selected by the absence of name, date of birth, and Social Security Number on their certificates. Main outcome measures were distributions by age, sex, and underlying cause of death and rates by sex, race, year, and state of death. An average of 413 unidentified persons died each year. The peak year was 1987 with 691 deaths, a rate of 28.5 per 10 million people. The rate declined to 9.7 per 10 million in 2004. Most unidentified decedents were male (80.6%). Unidentified death rates were highest among black people and in the Southwest. Among deaths for which the cause was known, 82.7% were due to injuries. Among injury deaths, 31.8% were homicides. Improvement in identification technology may have reduced rates of unidentified death since the 1980s. In addition, variations in rates of unidentified decedents may reflect changes in risk factors such as homelessness and substance abuse.     

A multifaceted,multijurisdictional, multiagency,and multidisciplinary approach to investigating unidentified and missing persons cases in Australia

Currently, there are approximately 750 unidentified human remains and 2500 long-term missing persons in Australia. The Australian Federal Police National DNA Program for Unidentified and Missing Persons (Program) is using a multifaceted, multijurisdictional, multiagency, and multidisciplinary approach in a dedicated effort to identify these unknown deceased persons, scientifically link them to known missing persons, and provide answers to their families. The nationally coordinated Program provides its police, forensic, and coronial stakeholders with a suite of contemporary forensic technologies, databases, and experts to forensically examine the skeletonised remains and recover post-mortem data for comparison to the available ante-mortem data for each missing person. Through a number of physical and virtual public outreach activities, families with missing relatives have been encouraged to provide vital ante-mortem forensic information, records, and samples to aid the identification process. To date, this unique Program has assisted to resolve a number of unidentified and missing persons cases from both historical and contemporary contexts, using a combination of genetic and non-genetic techniques, and local and national databases. The centralisation of Program capabilities, expertise, and resources to conduct this type of unique and challenging casework is proving to be the most effective and efficient way to generate investigative leads, identify human remains, and resolve long-term missing persons cases in Australia.     

Suicide by asphyxiation due to helium inhalation

Suicide by asphyxiation using helium is the most widely-promoted method of "self-deliverance" by right-to-die advocates. However, little is known about persons committing such suicides or the circumstances and manner in which they are completed. Prior reports of suicides by asphyxiation involving helium were reviewed and deaths determined by the North Carolina Office of the Chief Medical Examiner to be helium-associated asphyxial suicides occurring between January 1, 2000 and December 31, 2008 were included in a new case series examined in this article. The 10 asphyxial suicides involving helium identified in North Carolina tended to occur almost exclusively in non-Hispanic, white men who were relatively young (M age = 41.1 T 11.6). In 6 of 10 cases, decedents suffered from significant psychiatric dysfunction; in 3 of these 6 cases, psychiatric disorders were present comorbidly with substance abuse. In none of these cases were decedents suffering from terminal illness. Most persons committing suicide with helium were free of terminal illness but suffered from psychiatric and/or substance use disorders.     

Sudden epilepsy deaths and the forensic pathologist

Sudden unexpected deaths in epileptic persons are not rare events, most commonly encountered by the forensic pathologist rather than the clinician. Such deaths may represent 1-1.5% of all "natural" deaths certified by the medical examiner or coroner. The typical victim is a black male about 30 years of age who tends to abuse alcohol, with a history of generalized epilepsy for more than 1 year and likely for more than 10 years. There are a lack of obvious anatomic causes for the death at autopsy, but 60-70% of cases will have a lesion in the brain (most commonly old trauma) to explain the epilepsy. Most victims have no blood levels of anticonvulsant medications at the time of death. We have evolved a form for use by medical examiner/coroner's investigators at the scene to collect relevant information which will be of assistance to the pathologist in interpreting the case. Estimated prevalence of sudden epilepsy death, mechanisms, and other features of such cases are reviewed briefly.     

The predictive value of history and scene investigation for toxicology results in a medical examiner population

Medical examiner offices vary in the extent to which they pursue postmortem toxicology. Our office routinely tests decedents for ethanol and drugs of abuse, and we decided to evaluate the usefulness of our practice. We reviewed 1180 medical examiner cases examined in 2002-2003. History and scene investigation indicated that alcohol or drugs of abuse were likely to be detected in 369 cases, yet toxicology testing revealed an intoxicating substance in 589 cases, a prevalence of 50%. Screening for toxicology testing based on investigative findings had a sensitivity of 0.47, a specificity of 0.84, and a positive predictive value of 0.74. Moreover, even in the 811 cases where initial investigation did not suggest substance abuse, toxicology testing revealed at least 1 substance that was pertinent to the subsequent investigation in one third of the cases (260), and the intoxicating substance was sufficiently important to merit inclusion as a cause of death or contributing factor in nearly half of those cases (113). We conclude that investigation alone is ineffective at predicting the presence of intoxicating substances within decedents.     

Bodies found in the waterways of New York City

We reviewed the case records for all decedents recovered from the waterways of New York City over a three year period (1997-2000). The epidemiological profile, circumstances, toxicology findings, putrefactive changes, date of recovery, length of immersion, and injuries were examined. There were 123 deaths: 52 suicides, 50 undetermined, 16 accidents, and five homicides. The causes of death included: 97 drownings, 13 undetermined, and 13 other. Of all the floating decedents, 27% were without putrefactive change. All found after two or more weeks of immersion were recovered from November to May. The detection of ethanol and illicit drugs was 53% in the accident, 41% in the suicide, and 33% in the undetermined groups. Detection of ethanol and/or drugs of abuse is not a reliable criterion to distinguish suicide from accident. The identification of the deceased is pivotal for determining the manner of these deaths. Therefore, a great reliance is placed upon the medical investigator and the police (including the missing persons bureau) to determine the circumstances and identification of the decedent.     

National Association of Medical Examiners position paper on the medical examiner release of organs and tissues for transplantation

The medical examiner community plays a key role in the organ and tissue procurement process for transplantation. Since many, if not most, potential organ or tissue donors fall under medicolegal jurisdiction, the medical examiner bears responsibility to authorize or deny the procurement of organs or tissues on a case-by-case basis. This responsibility engenders a basic dichotomy for the medical examiner's decision-making process. In cases falling under his/her jurisdiction, the medical examiner must balance the medicolegal responsibility centered on the decedent with the societal responsibility to respect the wishes of the decedent and/or next of kin to help living patients. Much has been written on this complex issue in both the forensic pathology and the transplantation literature. Several studies and surveys of medical examiner practices, as well as suggested protocols for handling certain types of cases, are available for reference when concerns arise that procurement may potentially hinder medicolegal death investigation. It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings. The purpose of this position paper is to review the available data, the arguments for and against medical examiner release, and to encourage the release of organs and tissues in all but the rarest of circumstances.     

Who are the Unclaimed Dead?

Unclaimed dead are deceased persons with no known next of kin (NoK) or NoK was located but did not claim the deceased. Unclaimed dead in Marion County, Indiana, 2004–2011, are examined. Comparisons are provided of the unclaimed to the claimed dead population and county death patterns. Race, gender, marital status, age, location, manner and cause of death, NoK, and days to disposition are analyzed. The unclaimed dead were disproportionately male, slightly more likely to be Black, younger at death, died from natural causes, had unknown marital status, were equally likely as not to have NoK, did not die in a hospital, and were subject to autopsy. Nearly half the unclaimed had NoK who did not claim the body; the other half had no identifiable NoK. Unclaimed were more likely to have an autopsy and to die from external causes. Most unclaimed were identified by means outside fingerprints or DNA.     

Suffocation using plastic bags: a retrospective study of suicides in Ontario, Canada

One hundred and ten cases of suicidal suffocation using a plastic bag were identified in the files of the Office of the Chief Coroner of Ontario, Canada, between 1993 and 1997. The records were reviewed to determine the demographic characteristics of this group compared with all cases of suicide in Ontario, the scene information, autopsy findings and toxicology results. Most suicides occurred in people over 60 years of age, with older women making up a considerable proportion of cases as compared with other methods of suicide. In 40% of cases the deceased was suffering from a serious illness. Autopsy findings were usually minimal, with facial, conjunctival and visceral petechiae present in a minority of cases. One or more drugs were detected in the blood in 92.6% of cases where toxicologic testing was performed. Benzodiazepines, diphenhydramine and antidepressants were the most common drugs found, with diphenhydramine the most common drug present at an elevated concentration. Information at the scene from "right to die" societies was uncommon. One quarter of decedents took additional measures, besides the use of drugs or alcohol, to ensure the rapidity, certainty or comfort of their death. This study further elucidates the characteristics of this uncommon method of suicide. It emphasizes additional scene findings, such as the presence of dust masks, physical restraints and modification of the plastic bag that may be of use to death investigators in determining the correct manner of death.     

Methadone-related deaths in Hennepin County,Minnesota: 1992-2002

Methadone maintenance therapy (MMT) is the only currently established medical therapy for heroin addiction. However, MMT still remains controversial. In Hennepin County, Minnesota, methadone is one of the top ten drugs reported in medical examiner investigated deaths and one of the most commonly diverted pharmaceuticals. This report reviews the role of methadone in medical examiner deaths over a 10-year period, 1992-2002. We compare cause and manner of death (accidental, natural, suicide) and methadone blood concentrations for decedents who were members of MMT programs with illicit users and those prescribed methadone for chronic pain. Findings reveal that 65% of decedents with measurable blood methadone concentrations were not participating in MMT programs. A total of 96 cases were identified, with the majority white (90.5%) and male (76.8%). MMTP program members were the minority (34.7%) of the methadone positive deaths and 39% were illicit users. Fifteen percent were chronic pain patients with almost half of this group dying from overdose. Methadone concentrations of drug caused/related deaths (0.18-3.99 mg/L) overlapped with those of deaths not attributable to methadone (0.18-3.03 mg/L) with no definable lethal level. Interpretation of methadone blood concentrations must be done in the context of the clinical history for determining cause of death, and may be confounded by postmortem redistribution.     

Interpretation,confidence and application of the standardised terms: Identified,Probable, Possible,Exclude and Insufficient in forensic odontology identification

Forensic odontology identification scales are used to express certainty of identifications of deceased persons. These standardized scales are assumed to convey unambiguous expert opinions and facilitate communication between forensic odontologists and end users. However, to date no studies have investigated how the experts interpret and use these scales.Forensic odontology identification scales are used to express certainty of identifications of deceased persons. These standardized scales are assumed to convey unambiguous expert opinions and facilitate communication between forensic odontologists and end users. However, to date no studies have investigated how the experts interpret and use these scales.This paper aims to examine the interpretation of the DVISYS forensic identification scale and choices of the levels in the scale subsequent to, and derived from, comparison of pairs of dental radiographs by extending the analysis of the data collected in the study by Page and Lain et. al. 2017.The studied variables: self-reported confidence, forced binary decision of match and non-match, choice of level in the DVISYS scale (Identified, Probable, Possible, Insufficient and Exclude) were further analysed in this study using mixed models for relationships between the choices of level in the identification scale and the fundamental beliefs of likelihood of identification.The results of this further analysis showed that the reported confidence of the decisions was correlated to the difficulty of cases, and as confidence decreased the use of less definitive terms (‘Probable’, ‘Possible’ and ‘Insufficient’) increased. ‘Probable’ and ‘Possible’ were used mainly in underlying beliefs below that of ‘Identified’ whereas ‘Insufficient’ was used mainly to convey a sublevel of ‘Exclude’. The use of ‘Insufficient’ in this study was not consistent with the prescribed definition of the term.The participants of the original study were not aware of the difficulty grading of the cases nor were required to grade them, however the reported confidence was systematically correlated to difficulty. Furthermore, indicated confidence level was correlated with choice of level on the scale in general, but the interpretation of the definition and application of the terms varied.The findings reported here contribute to the foundational knowledge of factors governing the interpretation and application of the DVISYS forensic odontology identification scale and suggest that this scale may need to be modified.     

Gunshot residue testing in suicides: Part I: Analysis by scanning electron microscopy with energy-dispersive X-ray

Several different methods can be employed to test for gunshot residue (GSR) on a deceased person's hands, including scanning electron microscopy with energy-dispersive x-ray spectroscopy (SEM-EDX) and inductively coupled plasma-atomic emission spectrometry (ICP-AES). Each of these techniques has been extensively studied, especially on living individuals. The current studies (Part I and Part II) were designed to compare the use and utility of the different GSR testing techniques in a medical examiner setting. In Part I, the hands of deceased persons who died from undisputed suicidal handgun wounds were tested for GSR by SEM-EDX over a 4-year period. A total of 116 cases were studied and analyzed for caliber of weapon, proximity of wound, and results of GSR testing, including spatial deposition upon the hands. It was found that in only 50% of cases with a known self-inflicted gunshot wound was SEM-EDX positive for at least 1 specific particle for GSR. In 18% of the cases there was a discernible pattern (spatial distribution) of the particles on the hand such that the manner in which the weapon was held could be determined. Since only 50% of cases where the person is known to have fired a weapon immediately prior to death were positive for GSR by SEM-EDX, this test should not be relied upon to determine whether a deceased individual has discharged a firearm. Furthermore, in only 18% of cases was a discernible pattern present indicating how the firearm was held. The low sensitivity, along with the low percentage of cases with a discernible pattern, limits the usefulness of GSR test results by SEM-EDX in differentiating self-inflicted from non-self-inflicted wounds.     

Radiocarbon dating as tool to assist in triaging cases of unidentified human remains in Victoria,Australia: A case series

In cases where human remains are unidentified because there is no initial identification hypothesis, limited contextual information, and/or poor preservation, radiocarbon (¹⁴C) dating may be a useful tool to further assist with identification. Through measuring the amount of ¹⁴C remaining in organic material, such as bone, teeth, nail, or hair, radiocarbon dating may provide an estimated year of birth and year of death for a deceased person. This information, may assist in, establishing whether a case of unidentified human remains (UHR) is actually of medicolegal significance and therefore, requires forensic investigation and identification. This case series highlights the application of ¹⁴C dating to seven of the 132 UHR cases in Victoria, Australia. Cortical bone was sampled from each case and the level of ¹⁴C was measured to provide an estimated year of death. Four of the seven cases analyzed contained the levels of ¹⁴C consistent with an archeological timeframe, one contained a level of ¹⁴C consistent with a modern (i.e., of medicolegal significance) timeframe, and the results for the remaining two samples were inconclusive. Applying this technique not only reduced the number of UHR cases in Victoria but also has investigative, cultural, and practical implications for medicolegal casework in general.     

Gunshot residue testing in suicides: Part II: Analysis by inductive coupled plasma-atomic emission spectrometry

Several different methods can be employed to test for gunshot residue (GSR) on a decedent's hands, including scanning electron microscopy with energy dispersive x-ray (SEM/EDX) and inductive coupled plasma-atomic emission spectrometry (ICP-AES). In part I of this 2-part series, GSR results performed by SEM/EDX in undisputed cases of suicidal handgun wounds were studied. In part II, the same population was studied, deceased persons with undisputed suicidal handgun wounds, but GSR testing was performed using ICP-AES. A total of 102 cases were studied and analyzed for caliber of weapon, proximity of wound, and the results of the GSR testing. This study found that 50% of cases where the deceased was known to have fired a handgun immediately prior to death had positive GSR results by ICP/AES, which did not differ from the results of GSR testing by SEM/EDX. Since only 50% of cases where the person is known to have fired a weapon were positive for GSR by either method, this test should not be relied upon to determine whether someone has discharged a firearm and is not useful as a determining factor of whether or not a wound is self-inflicted or non-self-inflicted. While a positive GSR result may be of use, a negative result is not helpful in the medical examiner setting as a negative result indicates that either a person fired a weapon prior to death or a person did not fire a weapon prior to death.