Atlas of Forensic Pathology



INTRODUCTION In the United States, two main systems of death investigation exist: coroner and medical examiner. In coroner systems, each county has an elected or appointed coroner who is charged with investigating deaths that occur in that county. The required background for a coroner varies by state, with some coroners having only a high school education and no formal training in death investigation prior to becoming coroner, whereas other coroners are physicians with some coroners even being forensic pathologists. Once an individual is elected or appointed as coroner, the continuing education required for the position varies by state. In contrast to a coroner system, in a medical examiner system, most frequently, the medical examiner is a forensic pathologist; however, in a few states, the medical examiner may be a non-forensic pathologist physician. While coroner systems are always county based, medical examiner systems can be city, county, or state based. For example, the city of St. Louis has a medical examiner, the county of Dallas has a medical examiner, and the state of Utah has a medical examiner. In its statutes, each state has a list of scenarios that when a death occurs under that scenario, the death must be reported to the appropriate agency (either the coroner or the medical examiner, depending upon what type of system the death occurs in). While all states frequently list certain scenarios (eg, infants and deaths in custody), each state also fre quently has certain scenarios listed that are specific to their state and not listed in the stat utes of other states (eg, one state may require investigation into a death if the decedent was the victim of domestic abuse within the last year, whereas another state may not have this particular scenario listed in their statutes as requiring a death investigation). As the statutes are developed by politicians, quite frequently the listed scenarios under which a death must be investigated will vary depending upon their experience and preferences. Unfortunately, just because a death MUST be reported does not mean that it actually WILL BE reported. Individuals reporting deaths are most often medical providers, including physicians and nurses, and they often fail to report delayed traumatic deaths, instead attributing the death to the immediate cause of death and not the proximate cause of death.

BASICS OF DEATH INVESTIGATION The steps performed to investigate any given death can vary from a series of phone calls to one on-site visit to the location where the body was found to multiple on-site visits to where the body was found and where the actual injury causing the death may have occurred (Figure 3.1). While each death scene is unique, if certain basic steps are followed at each scene, with some variation based upon the nature of the scene investigation, each death will be properly documented. It must be remembered that the death scene investiga tion, as with the autopsy, can essentially only be performed once. While second (or more) autopsies and second (or more) scene visits can be performed, the utility of each repeat attempt is greatly diminished from the original effort, and the chance to document some if PEARLS & PITFALLS While coroners and medical examiners will most often not routinely review the death certificates for all deaths that occur in their jurisdiction, some of these non reviewed death certificates will apply to an individual who died a non-natural death and was not referred appropriately for a death investigation. While many states require the coroner or medical examiner to approve all cremation permits for deaths in their jurisdiction, which will allow for some of these non-investigated deaths to be identified, if the decedent dies from a certified natural cause and is buried, most often the death certificate will not be reviewed by the coroner or medical examiner. Having a good relationship with funeral homes with which the coroner or medical examiner works can assist with this problem, as the funeral director can flag death certificates that they feel may be non-natural deaths, and ensure that they are referred to the coroner’s or medical examiner’s office. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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