Manner Natural Marnie Wood MD FRCPC March 10

Manner: Natural Marnie Wood MD FRCPC March 10, 2015

Objectives • Gain a better understanding of the Nova Scotia Medical Examiner Service role, jurisdiction and responsibilities • Gain appreciation of the spectrum of natural disease falling under Nova Scotia Medical Examiner Service jurisdiction • Review case examples to illustrate Medical Examiner investigation into sudden/unexpected deaths

Introduction • Many think violent/suspicious deaths comprise the bulk of Medical Examiner case load

Introduction • Personally, Natural deaths comprise more than 50% of cases autopsied • The cause of death in the majority of these cases is some variety of ASCVD or chronic ethanol abuse • The remainder are some of the most interesting cases • Accident ~30%, Suicide ~ 10%, Homicide <5%, Undetermined <1%

Introduction • Fatality Investigations Act is the provincial legislation defining Medical Examiner jurisdiction, responsibilities and authority • Dictates specific categories of deaths legally required to be reported to the Medical Examiner Service

Introductions • Natural deaths may be reportable to the NSMES under several subsections of the Fatality Investigations Act • Medical Examiner may or may not accept the reported cases for further investigation by the NSMES

Per Fatality Investigations Act: • • • Death result of violence, accident or suicide Unexpectedly when in good health Where person not under care of a physician Where cause of death is undetermined Result of improper or suspected negligent treatment by a person

• Definition of unexpected varies markedly depending on perspective • Tragic does not equal unexpected • Age is not a criteria for accepting or declining cases

Notify ME where person dies in health-care facility and there is reason to believe: • Death result of violence, suspected suicide or accident • Death result of suspected misadventure, negligence or accident on part of attending physician or staff • Cause of death is undetermined • Stillbirth or neonatal death where maternal injury before admission or during delivery • Within 10 days of surgery, or during anaesthesia

• Cause of death is the disease or injury setting into motion the uninterrupted chain of events leading to death • Cause of death need not be determined with 100% certainty • Medical opinion based on reasonable interpretation of available data • No requirement to know every link in the chain with certainty • Ie: final mechanism of death may be unknown, but underlying cause certified with reasonable confidence

• Tragic does not equal unexpected, accidental or negligent • Threshold for NSMES taking jurisdiction over deaths during medical intervention tends to be high • • Accidental or intentional overdose of medication Injury from malfunction of equipment (eg electrocution) Procedure outside of scope of licensed practice Complication beyond reasonable/foreseeable

Notify of deaths in custody • Death while detained, or in custody in a correctional institution • While an inmate is in Hospital • While in custody under Children and Family Services Act • While detained by, or in custody of peace officer • NOTE: regardless of apparent cause or manner of death

Notify of death related to employment or occupation • Where person dies as result of: • Disease or ill health • An injury sustained by the person • A toxic substance introduced into the person Probably caused by, or connected with, the person’s employment

• If occupation-related illness exacerbated a co-morbidity, which became the Cause of death, generally consider death connected with employment

Typically do not take jurisdiction: • Natural Manner when sufficient clinical information with which to form reasonable opinion of cause of death • where mechanism of death was a reasonable/foreseeable complication of appropriate medical therapy/surgery for a Natural disease • Natural Manner where occupational exposure not connected in any way to the underlying cause of death

Typically do take jurisdiction over: • All accidents, homicides, suicides • All possible accidents, homicides, suicides • Where negligence is a consideration • All in custody deaths, regardless apparent cause or manner • All deaths possibly connected with occupation • Where insufficient clinical information to determine cause of death

Medical Examiner Responsibilities • …where Medical Examiner is satisfied death occurred under a circumstance in Sections 9 -12 (of Fatality Investigations Act), ME shall investigate and, where possible, establish: • • Identity of the person Date, time and place of death Cause of death Manner of death • (also answer case specific questions)

Thank you ? Questions or Comments? Marnie. wood@novascotia. ca