Strengthening Forensic Science in the United States A Path Forward (2009) / Chapter Skim
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9 Medical Examiner and Coroner Systems: Current and Future Needs
9 Medical Examiner and Coroner Systems: Current and Future Needs
Pages 241-268
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2003. Medicolegal Death Investigation System: Workshop Summary.
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. . Additionally, the 1928 committee recommended the development of medicolegal institutes, which would affiliate medical examiners with hospitals and universities. In 1932, another NRC committee produced a review of existing medicolegal collaborations, which were mostly located in Europe. This committee again advised a larger role for medical doctors within forensic science and criminal proceedings.10 In 1954, the National Conference of Commissioners on Uniform State Laws issued the Model Post-Mortem Examinations Act (the Model Act)
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About 2,342 medical examiner and coroner offices provided death investigation services across the United States in 2004.18 Individual state statutes determine whether a medical examiner or coroner delivers death investigation services, which include death scene investigations, medical investigations, reviews of medical records, medicolegal autopsies, determination of the cause and manner of death, and completion of the certificate of death.
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Second, as public health officers, they surveil for index cases of infection or toxicity that may herald biological or chemical terrorism, identify diseases with epidemic potential, and document injury trends. Additional ME/C responsibilities include the response to and investigation of all deaths resulting from all hazards, including terrorism and mass fatality events, and the identification of the unidentified dead.
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In total, there are approximately 2,342 separate death investigation jurisdictions.24 Of 1,590 coroner offices in the United States, 82 serve jurisdictions with more than 250,000 people; 660 medium-sized offices serve between 25,000 and 249,999 people; and 848 offices serve small jurisdictions 21 J.C.U. Downs, Board Member and Chair, Governmental Affairs Committee, National Association of Medical Examiners; Vice Chair, Consortium of Forensic Science Organizations; Coastal Regional Medical Examiner, Georgia Bureau of Investigation.
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of fewer than 25,000 people.25 The hodgepodge and multiplicity of systems and controlling statutes makes standardization of performance difficult, if not impossible. Some observers believe that a revisiting of the model code is required, as has been proposed by numerous study groups over the years, in order to work toward the development of a modern model code for death investigation systems that utilizes new and available technologies that are responsive to the needs of the citizens.26 25 Ibid.
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Options for improving death investigation by coroners include (1) replacing coroner systems with medical examiner systems; (2)
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The disconnect between the determination a medical professional may make regarding the cause and manner of death and what the coroner may independently decide and certify as the cause and manner of death remains the weakest link in the process. In contrast, medical examiners are almost always physicians, are appointed, and are often pathologists or forensic pathologists.
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staff members, while offices serving populations of 1 million or more employ an average of 50 FTEs.34 Competent death investigations require that trained medical death investigators attend scenes; medically credentialed persons perform external physical examinations; and forensic pathologists perform medicolegal autopsies, employ and 33 V Weedn.
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No matter what the level of quality of other forensic science disciplines that are supported by a particular jurisdiction may be, if the death investigation does not include competent death investigation and forensic pathology services, both civil and criminal cases may be compromised. All ME/Cs share the following deficiencies to some degree: • imperfect legal structure/code controlling death investigations; • nadequate expertise to investigate and medically assess decedents; i • inadequate resources to perform competent death investigations; • nadequate facilities and equipment for carrying out body views i and conducting autopsies; • inadequate technical infrastructure (laboratory support)
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Progress has been very slow. Additional impediments to progress include the need for some states to change state constitutions or codes, the political constituent base underpinning local coroners, insufficient population and budget to support a competent independent system in small localities, an unwillingness to develop cooperative regionalization for provision of autopsy services, the shortage of physicians -- especially pathologists and forensic pathologists -- and lack of interest, advocacy, or the perception of need.38 To implement such conversions, the United States will require a national vision, a model code, increased numbers of forensic pathologists, and funding for infrastructure, staff, education, training, and equipment.
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NIJ and NAME have attempted to provide guidance for best practices. The NIJ document Death Investigation: A Guide for the Scene Investigator; Medicolegal Death Investigator: A Systematic Training Program for the Professional Death Investigator; the NAME Autopsy Standards and Inspection Checklist; and NAME's Forensic Pathology Autopsy Standards are available, but there is no incentive for death investigation systems to adopt them for use.40 Compliance is further limited because of heavy case loads, deficiencies in trained staff, absence of equipment, nonavailability of required day-today and consultative services, and the presence of contradictory policies and practices.
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There is no standard method of sample and data collection for ME/C systems. Multiple systems are commercially available that can be structured to meet the particular needs of any death investigation system.
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Virtopsy has the potential to detect internal bleeding, missile paths, bone and missile fragmentation, fracture patterns, brain contusion, and gas embolism, in addition to occult fractures that are technically difficult to demonstrate during the traditional autopsy. Although a standard forensic autopsy is needed to recover evidence such as bullets or bomb fragments within the body and to collect specimens for testing, virtopsy offers a valuable tool for examination when dissection of the body is not feasible, when evidence is hard to visualize, or when a more complete assessment of injury is desired in noncriminal cases.
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Many medical examiner offices archive a card with a dried blood sample on decedents, primarily to document personal identification, should the need arise, but also for future study. In the future, kin may request the archived blood cards, as the molecular diagnosis of disease improves and families seek to identify their risk.
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They receive death investigation training and are responsible for examining bodies that do not require medicolegal autopsy and, according to system guidelines, for referring cases that need autopsy to regional offices where forensic pathologists perform the examinations and initiate further investigation as needed. Well-trained local medical examiners keep costs in line by reducing transportation costs to regional or central offices and are more accessible than pathologists in distant offices.
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Forensic pathologists practice in multiple settings. Most operate within death investigation systems and are appointed as civil servants and serve as medical examiner forensic pathologists.
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The shortage of qualified forensic pathologists required to staff aspiring medical examiner systems constitutes a major challenge not only for offices that are currently seeking staff, but for the future as well. STANDARDS AND ACCREDITATION FOR DEATH INVESTIGATION SYSTEMS Currently, the standard for quality in death investigation for medical examiner offices is accreditation by NAME.
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QUALITY CONTROL AND QUALITY ASSURANCE Quality control and quality assurance begin with the implementation of standardized policies and procedures by qualified staff. For lay medical investigators, registration and certification by the American Board of Medicolegal Death Investigators requires standard performance procedures as outlined in the NIJ document Death Investigation: A Guide for the Scene Investigator and other published education and training documents.51 For forensic pathologists, basic competence is initially documented by examination and certification and subsequently by recertification by the American Board of Pathology.
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The College of American Pathologists offers self-assessment programs in anatomical and forensic pathology, as well as a continuing education program of forensic pathology case challenges.53 HOMELAND SECURITY As part of homeland security, the National Response Plan (National Response Framework as of March 2008) identifies ME/Cs under Emergency Support Function 8 as responsible for management of the dead resulting from any hazardous event.54 All deaths resulting from any form of terrorism are under the jurisdiction of the ME/C.
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In other countries, universities house a department of legal medicine and/or departments of forensic medicine and pathology where forensic pathologists have the time, expertise, and funding needed to perform basic forensic research. The Accreditation Council for Graduate Medical Education (ACGME)
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Even in universities that have a department of forensic science, research is limited to the forensic science disciplines, and little or no research is devoted to forensic pathology or forensic medicine. In some cases, there may be collaborative, ongoing epidemiological activities, such as when forensic pathologists work with members of departments of trauma surgery to develop statistical studies or when a forensic pathologist presents data at surgical or pediatric death review conferences.
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The major goals of MECISP were to improve medicolegal death investigation and to facilitate the sharing of death investigation information.61 Many agencies depend on ME/C investigations and autopsies to complete their work, such as the Occupational Health and 59 National Violent Death Reporting System. Available at www.cdc.gov/ncipc/profiles/nvdrs/ default.htm.
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As with other forensic science fields, there are no mandated national qualifications or certifications required for death investigators. Nor is medical expertise 62 SNOMED.
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Currently, requirements for practitioners vary from an age and residency requirement to certification by the American Board of Pathology in forensic pathology. Funds are needed to assess and modernize the medicolegal death investigation system, using as a benchmark the current requirements of NAME related to professional credentials, standards, and accreditation.
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NIFS also could work with groups such as the National Conference of Commissioners on Uniform State Laws, the American Law Institute, and NAME, in collaboration with other appropriate professional groups, to update the 1954 Model Post-Mortem Examinations Act and draft legislation for a modern model death investigation code. An improved code might, for example, include the elements of a competent medical death investigation system and clarify the jurisdiction of the medical examiner with respect to organ donation.
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(c) NIFS, in collaboration with NIH, the National Association of Medical Examiners, the American Board of Medicolegal Death Investigators, and other appropriate professional organizations, should establish a Scientific Working Group (SWG)
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(f) medicolegal autopsies should be performed or super All vised by a board certified forensic pathologist.
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