Medicolegal death

investigations
What is forensic medicine?
It is a branch of medicine that applies the principles and knowledge of the
medical sciences to problems in the field of law .
Deaths that come to the attention of the office of medical examiner or the
coroner generally fall into the following categories:
● Violent deaths: accidents ,suicides , and homicides.
● Suspicious deaths
● Sudden and unexpected deaths
● Deaths without physician in attendance
● Deaths in an institution
These are variable according to local jurisdiction
duties of a medicolegal system in handling deaths under its jurisdiction
• To determine the cause and manner of death

• To identify the deceased, if unknown

• To determine the time of death and injury

• To collect evidence from the body that can be used to refute

or corroborate an account of how the death occurred

• To document injuries or lack of thereof

• To deduce how the injuries occurred

• To document any natural disease present

• To determine or exclude other contributory or causative

factors to the death

• To provide expert testimony if the case goes to trial

So ,,injuries->evidence ->deceased ,cause , manner

->document.
Definition of death
In simpler times , death was defined as the permanent cessation of cardiac and/or respiratory function .
Today , instrumentation can keep a heart beating and and an individual breathing in spite of the fact that if this
machinery were turned off , the patient will die ! This has brought out the concept of brain death

Other issues that may arise ; procurement or organs and moving of brain dead individuals . If harvesting of organs
is intended , and if the case is to be a medical examiner’s or coroner’s case , prior to removal of organs , approval
must also me obtained from the medical examiner or the coroner

Another issue is who will perform

the examination of the body after
removal of organs .

Also the timing of death between

the time of brain death and the time
of removal of machines.
 Death certification
Two of the most important functions of the medical examiner’s or coroner’s office are the
determination of the cause and manner of death.
Before we proceed , let’s understand the difference between the cause , manner and
mechanism of death:
Simply put;
the cause of death is any injury or disease that produces a physiological derangement in the
body that results in the death of the individual.
The mechanism of death is the physiological derangement produced by the cause of death
that results in death. particular mechanism of death can be produced by multiple causes of
death and vice versa.
The manner of death explains how the cause of death came about.
causes of death: a gunshot wound to the head, a stab
wound to the chest, adenocarcinoma of the lung and
coronary atherosclerosis.

Examples of mechanism of death would be hemorrhage,

septicemia and cardiac arrhythmia.

Manners of death can generally be categorized as natural,

homicide, suicide, accident or undetermined. The authors
also use the category “unclassified.”
Not infrequently, the cause of death is listed as “cardiac arrest” or “cardiopulmonary arrest.” Simply
stated, this means that the heart stopped or the heart and lungs stopped. Experience tells us,
however, that when any individual dies, the heart and lungs stop. These are not causes of death
and, to a degree, are not even mechanisms of death.
 The manner of death
The manner of death as determined by the forensic pathologist is an opinion based on
the known facts concerning the circumstances leading up to and surrounding the
death, in conjunction with the findings at autopsy and the laboratory tests.

These may be inconsistent so further investigations will be warranted or the manner of

death will be changed .
However ,this not always the case!
Just because a forensic pathologist makes a determination as to the manner of death does not
mean that it will be accepted by either families or other agencies, ex : the police . For example, if
a widow, challenging a medical examiner’s opinion of suicide so that she can collect insurance,
brings two young children to the trial, it would not be surprising if the jury should decide to rule
the death an accident, no matter how much objective evidence had been presented to the
contrary.
Occasionally, there are cases in which the cause of death would ordinarily be considered natural,
but the manner is homicide, for example, a homeowner who surprises a burglar, engages him in
a violent struggle and then collapses and dies of a heart attack.
While manner of death is mainly determined by circumstances, the autopsy findings can still be
important in making the determination of the cause of death.(drowning)
 Undetermined manner of death
The undetermined manner of death is used when there is insufficient information about
the circumstances surrounding the death to make a determination, or, in some
instances, when the cause of death is unknown. Thus, if one finds the skeletonized
remains without evidence of trauma, one cannot say whether the manner of death was
accident, homicide or suicide, because the cause of death is not known.

Can you give examples? (Drug overdose , is it suicide or just overdose )

In some instances, based on the circumstances surrounding a death, a manner of death

can be determined without a cause of death ,ex ; homicide circumstances with free
autopsy.

So we can have determined cause with undetermined manner , undetermined cause

with determined manner , and undetermined cause and manner (sids)
 Unclassified manner
This refers to a death in which the cause and circumstances are known, but the
death does not readily fall into any of the before mentioned categories.
An example is the case of a woman who came into the hospital for an abortion. A
hypertonic saline solution was injected; the woman went into labor and delivered a
live 450-g infant. The infant displayed chemical bums of the skin due to the
hypertonic saline solution and survived an hour and a half without mechanical
assistance, prior to dying. The death does not fit neatly into any of the categories
of natural, accident, suicide or homicide and it is not truly undetermined as the
cause and circumstances surrounding the death are accurately known. Thus, a
manner of death of unclassified may be used.
The authors also place in the unclassified category cases that some individuals
call medical misadventure as unclassified.
Classification variability
sometimes the classification of manner of death is based on local precedent or
office policy. If two people are “kidding around” with a gun and one individual
points the gun at another and pulls the trigger, in some localities, this is classified
as an accident; in others, as a homicide.

If one drinks too much alcohol and dies of acute alcohol intoxication, this is an
accident. If one drinks too much alcohol every day for 15 years and develops
cirrhosis of the liver and chronic liver failure due to the alcohol, then the manner of
death is classified as natural.
Delayed deaths
Delayed deaths often cause issues with death certification as well as investigation.
What people often fail to realize is that the cause of death may still be traumatic
even if there is a long delay between injury and death, as long as the death was a
result of injuries:an individual died of chronic renal failure within a few hours of
admission to a hospital. However, renal failure was due to chronic pyelonephritis,
complicating paraplegia, which had in turn been caused by a gunshot wound to
the spine 25 years prior. Not only was the cause of death in this case the gunshot
wound, but the manner of death was also homicide.
Importance of death certificate
● used by families for legal and financial purposes
● provide emotional closures for families being the decedent’s last medical
record
● They may be used to determine familial genetic propensities or in genealogy
studies
● They are also used to identify emerging diseases, gauge the health of a
population and direct public health initiatives.
Statistics
While one of the main duties of medicolegal death investigation systems is to
investigate non-natural deaths, natural deaths still comprise a large portion of any
medical examiner/ coroner office. Most of these are the sudden and unexpected
deaths of individuals out functioning in the community, but who may not have
significant medical history or who did not routinely see a physician. The other large
category of deaths is usually accidental deaths, which encompass automobile
collisions and drug overdoses as well as falls in elderly persons. Only a minority of
medicolegal cases are actually homicides, which is often contrary to popular
belief.
 Death investigation systems

The coroner system The medical examiner

system
The coroner system
● It is the older of the two medicolegal systems. Firstly introduced in England.
● An individual who is not a physician is elected the coroner.
● The coroner makes rulings as to the cause and manner of death in cases that fall
under the coroner law, these cases constitute violent deaths, sudden and/or
unexpected deaths, suspicious deaths and cases in which a physician is not in
attendance at the time of death.
Who is the coroner?
● Not necessarily a physician, moreover the coroner is
not required to consult a physician for advice.
● The training the coroner receives for the position can
range from absolutely none to a few hours or 1–2
weeks.
● In some areas, this system has been modified such that
the coroner must be a physician, though not necessarily
a pathologist.
● The roles of the Coroner and Law Enforcement
intersect (Ethical conflict)
The medical examiner system
● Medical examiner system was first introduced in the United States in 1877.
● A physician who functioned as a “medical examiner” to determine the cause and
manner of death.
● The first true medical examiner system came into existence in 1918 in New York
City. Individual designated as chief medical examiner was to be a physician
experienced in the field of pathology (forensic pathology did not become a
subspecialty until 1959).
● The medical examiner could perform autopsies in cases where it was necessary like:
violent deaths , suspicious deaths, sudden, unexpected deaths and deaths occurring
within 24hrs after admission to hospitals.
 However, the creation of a medical examiner system does not necessarily
mean that a community actually has a functioning or effective medical
examiner system, nor does the fact that it once had one guarantee that it
will continue to operate in an effective manner.
 The coroner system
● Cheaper in some jurisdictions in the short
run because no experts or scientific
investigations are used, becomes more
expensive in the long run.
● The coroner system often produces inferior
and inaccurate results.
The medical examiner system
● Medical examiner system is relatively
inexpensive to operate, considering its
benefits.
● Well organized, depends on experts and
scientific investigation
Operation of medical examiner system

1. An adequate law under which to operate, under such a law, violent deaths (accidents,
suicides and homicides), suspicious deaths, sudden and unexpected deaths, deaths
without a physician in attendance and deaths in jails and penal institutions should fall
under the medical examiner’s jurisdiction. Medical examiners have the right to
perform an autopsy on any cases that they feel need one. the right to subpoena records
and individuals, if necessary. Deaths are to be reported to medical examiners
immediately after they occur or are discovered. The law should also provide medical
examiners with a certified toxicology laboratory.
Medical examiners should also have civil service protection. “medical examiners make
unpopular opinions”
2. A qualified person, The chief medical examiner should be a board-certified forensic
pathologist with a number of years of experience, there should be assistant medical
examiners who are also board-certified forensic pathologist.

3. the medical examiner’s office needs adequate staffing. Medical examiners alone do not
constitute an office. There must be competent investigative, administrative, secretarial and
technical support staff.

4. Must be an adequate facility, The facility must have sufficient space; an appropriate
floor plan; electrical, plumbing and cooling capabilities; and furnishings.

5. Adequate instrumentation available for the scientific investigation of death,

How should a medicolegal death investigation be approached?

History

Physical exam

Additional
investigations
● The history is not obtained from the patient, but from witnesses, relatives
of the deceased, police agencies, treating physicians and/or records
(medical, nonmedical, police, governmental, etc.). It is an account of the
events leading up to and surrounding the death.
● The medical examiner then performs a physical examination and laboratory
tests. The procedures may range from an external examination of the body
to a complete internal autopsy.
● Photographic documentation of autopsies is often also necessary,
photographs of the body be taken prior to examination with at least one
photograph of the face and head for use as an identification photograph.
Additionally, there should be photographic documentation of any
significant injuries
● Samples should be retained on every case for future testing, if needed.
(blood, urine and vitreous samples)
● Routine drug screens should be performed on almost all investigated deaths
● A genetic sample, such as a blood spot card, is obtained and retained for
every case, should future DNA testing be required.
● At the time of autopsy, tissue should be retained for possible microscopic
examination
● A specialized tests, sexual assault examinations
Investigators
In most major medical examiner systems, reports of deaths do not come directly to medical examiners, but to lay
investigators employed by the medical examiner’s office, who are trained to screen the cases and make a
determination as to whether a death is a medical examiner’s case.

If investigators accept the case as a medical examiner’s case, they often also attend the scene and take possession
of the body. If the body has been moved from the scene to a hospital, a scene examination is usually not
necessary and the body can be brought directly to the ME office. If the body is still at the scene, the investigator
should go to the scene and document all the findings at the scene regarding the body and to obtain a detailed
history of the circumstances leading up to and surrounding the death.

Depending upon jurisdiction, investigators come from a variety of backgrounds, including criminal justice,
nursing and anthropology; some have degrees in biological, psychological or physical or other sciences.
Regardless of previous training, investigators should be well versed in the local laws governing medicolegal
death investigation and should become certified as medicolegal death investigators
 FORENSIC CONSULTANTS

As part of a thorough death investigation, consultation with additional forensic experts

may be of assistance.

Forensic pathologist may require assistance from a forensic odontologist, especially for
issues of dental identification or bite mark analysis.
Thank you :)
-Lana malhis
-Rawan madani