ORIGINAL ARTICLE

Delayed Homicides and the Proximate Cause

Peter Lin, MD,*† and James R. Gill, MD*†

investigate and certify. The investigation of delayed homicides may

Abstract: Delayed homicides result from complications of remote injuries
be a challenge due to a number of issues including: failure to report
inflicted by “the hands of another.” The investigation of delayed homicides
the death to the proper authorities, lack of ready and adequate
may be a challenge due to a number of factors including: failure to report the
documentation of the original injury and circumstances, and juris-
death to the proper authorities, lack of ready and adequate documentation of
dictional differences between the place of injury and death. The
the original injury and circumstances, and jurisdictional differences between
certification of these deaths also requires a demonstration of a
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the places of injury and death. The certification of these deaths also requires the
pathophysiologic link between the remote injury and death. The
demonstration of a pathophysiologic link between the remote injury and death.
certification of such a death may be particularly problematic for
In sorting through these issues, it is helpful to rely upon the definition of the
police and prosecutors who may have to prosecute a 20-year-old
proximate cause of death.
homicide. In some instances, however, it may be relatively simple if
Over a 2-year period in New York City, there were 1211 deaths certified
the perpetrator previously had been identified and tried for attempted
as homicide of which 42 were due to injuries sustained greater than 1 year
murder or some degree of assault immediately following the original
before death. The survival interval ranged from 1.3 to 43.2 years. The most
injury. In some instances, the perpetrator still may be incarcerated
common immediate causes of death were: infections (22), seizures (7), and
for the prior (or other) offense.
intestinal obstructions/hernias (6). Common patterns of complications in-
These delayed homicides reiterate the importance of always
cluded infection following a gunshot wound of the spinal cord, seizure
determining the proximate cause of death. The proximate cause of
disorder due to blunt head trauma, and intestinal obstruction/hernia due to
death is that which in a natural and continuous sequence, unbroken
adhesions from an abdominal stab wound. Spinal cord injuries resulted in
by any efficient intervening cause, produces the fatality and without
paraplegia in 14 instances and quadriplegia in 8. The mean survival interval
which the end result would not have occurred. It must be an
for paraplegics was 20.3 years and 14.8 years for quadriplegics; infections
etiologically specific disease or injury. Due to a prolonged survival
were a frequent immediate cause of death in both groups, particularly
interval, some deaths may not be immediately recognized as due to
infections due to chronic bladder catheterization.
injury and therefore not reported to the police or medical examiner/
The definition of proximate cause originated with civil law cases and was
coroner. Clinical physicians often focus on mechanisms and imme-
later applied to death certification as the proximate cause of death. The
diate causes when they certify a death. Therefore, there is a risk that
gradual extinction of the “year and a day rule” for the limitation of bringing
some of these delayed homicides may be missed. The treating
homicide charges in delayed deaths may result in more of these deaths going to
physician mistakenly may certify the death as bronchopneumonia
trial. Medical examiners/coroners must be able to explain the reasoning
(natural) and disregard the fact that the patient was ventilator-
behind these death certifications and maintain consistent standards for the
dependent for 5 years due to a gunshot wound of the upper cervical
certification of all delayed deaths due to any injury (homicides, suicides, and
spinal cord. This is a fairly common occurrence in medicolegal
accidents).
death investigation.
Key Words: forensic pathology, homicide, proximate cause, delayed
complications
MATERIALS AND METHODS
(Am J Forensic Med Pathol 2009;30: 354 –357)
The New York City Office of Chief Medical Examiner
investigates all unexpected, violent, and suspicious deaths in New
York City. By statute, these deaths must be reported to the Office of
Chief Medical Examiner. We reviewed all medical examiner death
D elayed homicides result from complications of remote injuries
inflicted by “the hands of another.” With the current state of
emergency medical services and long-term care advances, some
certificates for all homicides that occurred between January 1, 2005
and December 31, 2006. Over this 2-year period, there were 1211
life-threatening injuries are not immediately fatal. The morbidity homicides. In 42 of these, the ultimately lethal injury occurred
associated with survival, however, may ultimately result in death.1 greater than one year before death. We reviewed the medical
For death certification purposes, there is no time limit for the interval examiner records which included the autopsy, toxicology, and in-
between the proximate (underlying) cause and death. Even though vestigators’ reports. One death did not undergo autopsy because the
an injury may have occurred years prior to death, if there is a direct, hospital mistakenly certified the death as natural and the remains
unbroken link, without an efficient intervening cause, between the were buried.
initial injury and death, the injury is the proximate cause of death The cause of death is defined as the etiologically specific
and dictates the manner of death.2 disease and/or injury responsible for initiating the lethal sequence of
A suspected homicide due to an injury that occurred years events (part 1 on the death certificate). A competent cause of death
before death is often difficult for a medical examiner/coroner to includes the proximate (underlying) cause. Immediate causes are
complications of the underlying cause interposed between the prox-
imate cause and fatal result. Mechanisms are etiologically nonspe-
Manuscript received March 22, 2007; accepted June 4, 2007.
From the *Department of Forensic Medicine, New York University School of
cific alterations in physiology and biochemistry whereby the causes
Medicine, New York, NY; and †New York City Office of Chief Medical exert their lethal effects (eg, exsanguination).3 Immediate causes
Examiner, New York, NY. and mechanisms are not required to be listed on the death certificate.
Reprints: James R. Gill, MD, Office of Chief Medical Examiner, 520 First In some deaths, there may be a contributing condition (part 2) that
Avenue, New York, NY 10016. E-mail: jgill@ocme.nyc.gov.
Copyright © 2009 by Lippincott Williams & Wilkins
contributed to death but did not result in the underlying cause listed
ISSN: 0195-7910/09/3004-0354 in part 1. There is no time limit for the proximate cause to result in
DOI: 10.1097/PAF.0b013e3181c1582a death. If there is a direct, unbroken, link between a remote injury and

354 | www.amjforensicmedicine.com Am J Forensic Med Pathol • Volume 30, Number 4, December 2009
Am J Forensic Med Pathol • Volume 30, Number 4, December 2009 Delayed Homicides

TABLE 1. Proximate and Immediate Causes of Death TABLE 3. Paralysis Survival Intervals
Immediate Cause Ventilator Decubitus Survival Interval
Type of Paralysis Total Dependent Ulcers in Years (Mean)
Intestinal
Obstruction/ Paraplegia 14 0 13 (93%) 8.3–32 (20.3)
Proximate Cause Total Infection Seizure Hernia Other Quadriplegia 8 7 6 (75%) 1.8–31 (14.8)
Gunshot wound 27 19 3 2 3 Hypoxic-ischemic 7 4 2 (29%) 1.3–13.5 (7.4)
encephalopathy
Blunt injury 9 4 4 1 1
Hemiplegia 2 0 0 2–12.3 (7.1)
Sharp injury 6 0 0 4 1
No paralysis 11 0 0 1.3–43.2 (18.4)
Total 42 23 7 7 5
Total 42 11 21 1.3–43.2 (15.7)

TABLE 2. Immediate Causes of Death

TABLE 4. Paralysis and Immediate Causes of Death
Infection 23
Intestinal
Bronchopneumonia 7
Obstruction/
Urinary tract infection 3 Type of Paralysis Total Infection Seizure Hernia Other
Decubitus ulcer 3
Paraplegia 14 12 0 0 2
Combination 10
Quadriplegia 8 6 0 1 1
Posttraumatic seizure disorder 7
Hypoxic-ischemic 7 3 2 1 1
Intestinal obstruction/hernia 7 encephalopathy
Other 5 Hemiplegia 2 1 1 0 0
No paralysis 11 1 4 5 1
Total 42 23 7 7 5
the immediate cause or mechanism of death, the injury is the
proximate cause of death. If there is an efficient intervening cause
then the remote injury is not the underlying cause of death. There were 29 injuries that resulted in paralysis including 14
The manner of death is determined from the circumstances paraplegics (2 cervical and 12 thoracic injuries), 8 quadriplegics, 2
and cause of death. The manners of death listed on the United States hemiplegics, and 7 with hypoxic-ischemic encephalopathies (Table
Standard Certificate of Death include: natural, accident, suicide, 3). Of 9 people who died with urosepsis, 8 had documented indwell-
homicide, and undetermined.3 In New York City, deaths also may be ing urinary tract catheters and included 5 paraplegics, 2 quadriple-
certified as therapeutic complication.4 The medicolegal definition of gics, 1 hemiplegic, and 1 hypoxic-ischemic encephalopathy patient.
homicide is defined as death at the hand of another or death due to There were 2 quadriplegics who survived over 30 years after the
the hostile or illegal act of another.5 Demonstration of the intent to injury. One had required placement of a tracheostomy 4 weeks
kill is not needed for a homicide interpretation. In addition, the before death due to infectious complications. The other was not
susceptibility or vulnerability of the victim does not absolve the ventilator dependent. The immediate causes of death for the para-
proximate injury. If the injury contributed to death, it will dominate lyzed patients are provided in Table 4.
the determination of the manner of death.
DISCUSSION
RESULTS
There were 42 homicides in which the proximate injury Proximate Cause
occurred greater than one year before death. The decedent’s average The term proximate cause originated in civil law. In 1908, the
age was 42.8 years and ranged from 7 to 84 years. There were 34 legal definition of proximate cause was given in the Pawsey versus
males and 8 females. The survival interval following the injury Scottish Union and Nation decision: “Proximate cause means the
ranged from 1.3 to 43.2 years with a mean of 15.7 years. The active, efficient motion that sets in motion a train of events, which
proximate and immediate causes of death are listed in Table 1. In 6 brings about a result, without the intervention of any force started
deaths, there were additional conditions that contributed to the and working actively from a new and independent source.” Pawsey
death. These included: hypertensive and atherosclerotic cardiovas- involved an insurance claim due to a fire in Kingston, Jamaica,
cular disease, diabetes mellitus, methadone intoxication, and AIDS. following the 1907 Jamaican earthquake. The issue was whether the
The most common immediate cause of death in this series fire was the result of the earthquake which would have been an
was infection-related and involved 23 deaths (Table 2). Seven deaths exclusion under the insurance policy. The case was appealed to the
were due to small bowel obstructions or incarcerated hernias that British Privy Council which agreed with the jury decision that there
were complications of remote injuries. Seven deaths were due to was reasonable doubt that the fire was started by the earthquake.6
posttraumatic seizures. The 5 other immediate causes included 1 Legally, it has been refined to the initial act that sets off a natural and
pulmonary embolism, acute and chronic rejection of a liver allograft continuous sequence of events that produces injury. In the absence
(transplanted due to a stab wound), an infection complicating cath- of the initial act, which produces injury, no injury would have
eters placed for hemodialysis which resulted from a complication of resulted (see also Palsgraf v. Long Island Railroad Co., 162 N.E. 99.
a gunshot wound, and 2 hemorrhagic complications. One bleeding N.Y. 1928). In malpractice claims, one element that a plaintiff must
complication involved a tracheoinnominate artery fistula due to a establish is that a breach of duty was the proximate cause of the
long standing tracheostomy and the other was a retroperitoneal injury. In 1948, the Sixth Decennial International Revision Confer-
hemorrhage during anticoagulation therapy for a deep venous ence agreed that vital statistics must code the underlying cause of
thrombosis complicating paraplegia due to a gunshot wound. death.5 They defined the underlying cause of death as: the disease or

© 2009 Lippincott Williams & Wilkins www.amjforensicmedicine.com | 355

Lin and Gill Am J Forensic Med Pathol • Volume 30, Number 4, December 2009
injury that initiated the train of morbid events leading directly to
death or the circumstances of the accident or violence, which
produced the vital injury. Their design of the new death certificate
included separate entries for the cause, manner, and circumstances
of death.7 From this similar terminology, it appears that the medi-
colegal definition of the proximate cause of death had its origin in
the legal definition of proximate cause.
In law, a proximate cause is an event sufficiently related to a
legally recognizable injury to be held the cause of that injury. The
legal use of proximate cause mainly is concerned with torts and the
assignment of negligence; however, there are logical similarities
with the use of proximate cause of death by the medicolegal field.
There are 2 types of causation in the law, cause-in-fact and proxi-
mate (or legal) cause. Cause-in-fact is determined by the “but-for”
test: but for the action, the result would not have happened. For
example, but for running the red light, the collision would not have
occurred. For an act to cause harm, both tests must be met;
proximate cause is a legal limitation on cause-in-fact. Since “but-
for” causation is very easy to show and does not assign culpability
(but for the snow, you would not have crashed your car), there is a
second test used to determine whether an action is close enough to
a harm in a “chain of events” to be a legally culpable cause of the
harm. This test is the proximate cause.
These tests of causality can be applied for death certification.
The critical task in certifying a death following a remote injury is to
determine whether the remote injury represents the proximate (un-
derlying) cause of death. A prototypical example is a wheelchair-
bound paraplegic (due to a remote gunshot wound of the spinal cord)
who dies from sepsis due to infected decubitus ulcers. In this
example, there are at least 3 injuries that meet the “but for”
test—-gunshot wound, paraplegia, and decubitus ulcers—-but only
the gunshot wound meets the proximate cause test. The search for
the proximate cause ends with the determination of the etiologically
specific disease or injury.
Delayed Homicides and Immediate Causes
An antiquated English common law rule holds that a death
must occur within a “year and a day” after an assault to be
considered a homicide. This rule has occasionally been invoked as
a defense in jurisdictions where it had yet to be explicitly revoked
(see State of Wisconsin v. Picotte, 2003 WI 42). A US Supreme
Court ruling in July 2001 affirmed a State Court’s abolishment of the
rule (Rogers v. Tennessee, US 99 – 6218) stating that “advances in
medical and related science have so undermined the rule’s useful-
ness as to render it without question obsolete.” It also was abolished
in Great Britain with the Law Reform Act of 1996. The gradual
extinction of the “year and a day rule” for bringing homicide charges
in delayed deaths, may result in more of these deaths proceeding to
trial. Medical examiners/coroners must be prepared to explain the
reasoning behind these death certifications and maintain consistent
standards for the certification of all delayed deaths due to any injury
(homicides, suicides, and accidents).
Medical examiner/coroners have no time limit for the interval
between an injury and death to invoke the injury as the proximate
cause. Therefore, the potentially long interval that may occur be-
tween a traumatic injury and death can complicate the cause of death
determination. Common problems include the failure of care pro-
viders to recognize and report deaths due to remote traumatic
injuries, the difficulty in sorting out a complex sequence of events
interposed between the injury and death, and the lack of adequate
documentation of the original injury and its circumstances. This
application of the proximate injury in delayed deaths is not only
applied to homicides. Delayed deaths due to injuries regardless of
the circumstances (accidents, suicides) also are certified with this
method.
356 | www.amjforensicmedicine.com
It is important to note that a medical examiner/coroner’s
determination of homicide as a manner of death is not equivalent to
a determination of homicide by a judge or jury. Certification of the
manner of death by a medical examiner/coroner is primarily for vital
health statistical purposes but also is used by insurance companies
and other agencies for internal administrative purposes. The cause of
death certification may be more important in subsequent legal
proceedings because it requires the gathering of facts obtained
through a medicolegal investigation, including an autopsy, and the
specialized knowledge to interpret those facts. In criminal trials, the
manner of death is ultimately a question for the jury to answer.
Nonetheless, the certification of a homicide requires a higher
degree of certainty (ie, a reasonable degree of medical certainty)
than natural deaths or accidents (a preponderance of the evidence).5
In deaths due to recent injury, it usually is not difficult to meet this
higher standard since the mechanism of death (eg, exsanguination)
is clearly linked to the injury. When trauma kills so quickly that
there is no time for sequelae to develop, the injury is both the
immediate and proximate cause of death.8 In delayed deaths, there
typically is an interposing immediate cause. These immediate causes
(bronchopneumonia, urosepsis) may result from natural diseases as
well as consequences of injury. Therefore, in these delayed deaths,
one must link the death to the immediate cause and link the
immediate cause to the remote injury. Both links must be made to a
reasonable degree of medical certainty to certify the death as a
homicide. This higher standard may be difficult to meet in some
instances of delayed death and typically requires a diligent review of
available records and an autopsy (particularly if competing or
contributing conditions unrelated to the remote injury are a concern).
The cause of death may be affected by the detection of other
non–injury-related comorbidities. The incidence of life-threatening,
cardiovascular disease increases with increasing age. In our series,
10 decedents were over 60 years of age and there were some deaths
in which coexisting natural disease made a contribution to the death.
The decision to include these contributing conditions depends upon
a careful review of the circumstances and autopsy findings. The 3
questions that arise with concurrent natural disease are: (1) is the
comorbidity to the extent that it is an efficient intervening cause of
death? (2) Did the comorbidity contribute to the death in conjunction
with the remote injury? (3) If so, was it a major or minor factor?
Contrariwise, if the remote injury contributes at all to the death, then
the injury will dominate the manner of death determination. For
example, one delayed homicide was certified as cardiac arrest due to
hypertensive disease (in part 1). This death occurred during emer-
gent surgery for an incarcerated incisional hernia due to a remote
repair of a stab wound, which was listed as a contributing condition
(part 2). The manner was certified as homicide.
There is a potential for obfuscation or confusion with the
immediate cause. Particularly in legal proceedings, a party may
attempt to blame the death on the immediate cause, ignore the
proximate cause of death, or focus on comorbidities. In some
instances, there may be an attempt to shift the blame to the care-
takers who did not “adequately” care for the patient. These diver-
sions usually can be addressed by the simple fact that this person
would not have died at this time from this complication if the
original injury had not occurred. The patient would not have re-
quired an indwelling urinary catheter or developed a decubitus ulcer
if there was no initial injury. It has been said that the constitution
does not guarantee an assailant the right to a healthy victim nor to a
doctor who knows how to fix a broken leg. As Adelson noted: “If a
wound not necessarily fatal, leads to the development of septic or
other complications which terminate fatally, the person causing such
a wound is responsible for the death as though the wound he
inflicted were necessarily fatal. Nor will the fact that the victim
© 2009 Lippincott Williams & Wilkins
Am J Forensic Med Pathol • Volume 30, Number 4, December 2009
might have recovered had a neglected wound been properly treated
relieve an assailant of responsibility for causing the death if the
original injury was feloniously inflicted.”8 Contrariwise, if a “wound
is not mortal and death results from an independent cause,” then this
is an example of an efficient intervening cause and the death would
not be certified as homicide.8
The morbidity and mortality associated with both paraplegia
and quadriplegia are well described in the medical literature.9,10
Studies on paraplegics and quadriplegics have demonstrated long-
term survival. A study of nonventilator-dependent patients who
survived a traumatic spinal cord injury (without concurrent moder-
ate or severe brain injury) incurred between 25 and 34 years of age
in Ontario, had a median survival of 38 years postinjury.10 They also
found a difference in the median survival time for paraplegics and
quadriplegics (41 vs. 32 years postinjury). Factors that affect mor-
tality include age at the time of injury and year of injury. Injury at
younger ages experience better survival outcomes and, due to
treatment improvements, injuries that occurred after the early 1970s
also have a decreased mortality. There have been conflicting data on
whether the vertebral level of injury predicts mortality.10 A study in
Great Britain examined long-term survival in over 3000 individuals
with spinal cord injuries that occurred over a 50-year period.9 They
found the top 3 “causes” of death were: pulmonary infection, urinary
system complications, and heart disease. Men were 75% more likely
than women to die of urinary system disease. Our data show a high
number of infection deaths in the patients with paralysis. Decreased
ambulation affects many aspects of the body including the cardio-
pulmonary system (deconditioning11), skin integrity, and genitouri-
nary dysfunction with the chronic need for bladder catheterization.
Infections due to chronic bladder catheterization are a well-de-
scribed complication in patients with spinal cord injuries.12–15
Posttraumatic seizures are a well recognized complication of
brain injury.16 –19 Posttraumatic seizures are categorized as early
(within one week of the injury) and late (after 1 week). Annegers et
al studied over 4500 children and adults with traumatic brain
injury.16 They found significant risk factors for later seizures in-
cluded brain contusion with subdural hematoma, skull fracture, loss
of consciousness or amnesia for more than 1 day, and an age of 65
years or older. Seizures following penetrating war injuries also have
been reported.19 The risk of posttraumatic seizures after severe head
injury is 7.1% within the first year and 11.5% within 5 years.18
Approximately 5.5% of all patients with a diagnosis of epilepsy have
a history of head trauma and the incidence of having at least one late
seizure in patients treated for a head injury is about 2%.17,18 The risk
of developing posttraumatic seizures extends for years following the
injury with approximately 50% occurring within the first year after
the injury.19
In summary, this is a series of 42 delayed homicides over a
2-year period in a large metropolitan medical examiner jurisdiction.
To our knowledge, a previous series of delayed homicides has not
been reported. Common scenarios of delayed homicides include:
infected decubitus ulcers, bronchopneumonia, and urosepsis due to
© 2009 Lippincott Williams & Wilkins
Delayed Homicides
paralysis following gunshot wounds of the spinal cord; seizures
following blunt head injuries; and small bowel incarceration/hernia
following stab wounds. In making consistent and accurate cause of
death determinations in delayed homicides, it is important to rely
upon the definition of proximate cause of death.
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