The Vermont Medical Examiner System Paul L Morrow

The Vermont Medical Examiner System Paul L. Morrow, MD Forensic Pathologist, Glebe, NSW Former Chief Medical Examiner, VT USA

Death Investigation • Functions – Cause of death • Mechanism of death – Manner of death – Identification – Time of death – Location of death

Death Investigation: Key Concepts • Cause of death – That disease or event that set in motion the medical chain of events that resulted in death • Mechanism of death – That medical chain of events that resulted in death

Death Investigation: Key Concepts • Manner of death – One word summary of circumstances of death – Manners of death • • • Natural Accident Suicide Homicide Undetermined

Death Investigation: Types of Death Investigator Systems • Coroner • Medical Examiner

Death Investigation Systems: Coroner – Ancient English office • Norman Conquest • Officially established 1194 – Appointed judicial officer (Australia/England) • Qualifications: legal (& medical in England) – Elected office in US • Qualifications: varied

Death Investigation Systems: Medical Examiner – American innovation • Massachusetts , first state ME law - 1877 • New York City, ME replaced coroner- 1915 • Maryland, first statewide ME System- 1939 – Appointed medical officer • Qualifications: medical, usually forensic pathologist

Death Investigation Systems • Australia/England – Coroner System • United States – Medical Examiner - 22 states • 19 state wide – Coroner - 11 states – Mixed - 18 • Canada – Medical Examiner - 4 provinces – Coroner - 8 provinces

Vermont: example of a rural death investigation system • State-wide Office of Chief Medical Examiner : – Oversees local medical death investigation – Backs up local death investigation – Performs autopsies

VERMONT Population(2005): 623, 050 Area: 9, 250 sq mi (24, 000 sq k)

Vermont Medical Examiner System: History • Before 1950’s – Town Selectmen, AG, SA, Sheriff/Local PD • Late 1940’s – Dr. Joseph Spelman – Creation of Vermont State Police – Design of Medical Examiner System

Vermont Medical Examiner System: History • Early 1950’s – M E laws passed – Medical Examiner System established with physician RME’s • Late 1990’s – early 2000’s – Crisis in RME System – Law amended to create AME – AME system established

Vermont State wide Medical Examiner System: Case #’s • ca. 800 case referrals annually • ca. 400 autopsies annually

VT ME System: staff • Office of Chief Medical Examiner – – 2 -3 pathologists (CME/DCME) Administrative staff LME coordinator Police investigator/liason (VSP) • Local Medical Examiners – Assistant ME’s – Regional ME’s • Toxicology, histology, other lab services by contract

VT Medical Examiner System • ME Statute (T 18§ 505509; 5205) – Medical Examiner Jurisdiction – Death Investigative Team – Authority to Order Autopsies

Medical Examiner Jurisdiction • Violence • Suddenly when in apparent good health • Unattended by a physician • Casualty • Suicide • As a result of injury • Jail or prison • Mental institution • Unusual, unnatural or suspicious circumstances

Jurisdiction: Thumbnail Sketch • All non-natural deaths (or deaths suspected to be nonnatural ) – Accidents, suicides, homicides • Sudden unexplained apparently natural deaths • Jail, prison or mental institution • Truly unattended deaths • Hazard to public health, welfare or safety

The Death Investigative Team • Medical Examiner – Chief Medical Examiner – Regional Medical Examiner – Assistant Medical Examiner • Law Enforcement Officer • State’s Attorney

The Death Investigative Team Medical Examiner • Responsible for the investigation of medical aspects of death • Determines the cause of death • Certifies the cause and manner of death (responsible for the death certificate)

The Death Investigative Team Chief Medical Examiner • Forensic Pathologist • Appoints regional and assistant medical examiners (RME’s & AME’s) – Supervises AME’s and RME’s • Authority to authorize autopsies • Performs autopsies

The Death Investigative Team Regional Medical Examiner • Physician • Appointed by the Chief Medical Examiner • Investigate medical aspects of death – May draw toxicology samples and such • Signs death certificate when there is no autopsy

Problem in Rural Death Investigation: In 1990’s Increasing Maldistribution of RME coverage • Inability of dispatchers to find RME to respond to call • Inability of RME’s to respond when called • Increasing difficult of OCME to act as RME, especially in distant regions of the state • Difficulty recruiting new physicians to replace RME’s as they retired

Increasing Maldistribution of RME coverage 1987 1997

The Death Investigative Team Assistant Medical Examiner • Qualified medical professional (as defined by CME) – Nurse, experienced EMT, physician’s assistant – Trained by OCME • • • Responds to calls/initial triage Visits scene of death Investigates medical aspects of death May draw toxicology samples Death certified by OCME or RME

The Death Investigative Team Law Enforcement Officer • Investigates the circumstances of death • Is responsible for all law enforcement aspects of death investigation – State’s Attorney creates list of qualified law enforcement officers

The Death Investigative Team State’s Attorney • Has jurisdiction of body • Authority to authorize an autopsy • Is responsible for “legal” aspects of death investigation, including any prosecutions • Creates list of qualified law enforcement death investigators

Autopsies: VSA 18 § 5205 • Authority: Chief Medical Examiner and State’s Attorney – “necessary and in the interest of public health welfare and safety, or in furtherance of the administration of the law” • Performed by (or under supervision of) Chief Medical Examiner • Report submitted to State’s Attorney and Attorney General

Indications for Autopsy: - Medical - Legal

Criteria for autopsy: legal • State’s Attorney – To determine or document cause and manner of death in cases of criminal investigation or “legal” interest – To identify medical factors in criminal and “legal” investigations – To gather evidence “in furtherance of the administration of the law” (e. g. , homicides)

Criteria for autopsy: medical • Chief Medical Examiner – To determine the cause and manner of death – To document the medical cause and mechanism of death – To gather necessary material to determine cause of death ( e. g. drug deaths) – To identify contributory medical factors – To “rule out” alternative causes where diagnosis is by circumstances (e. g. hypothermia, hyperthermia, drowning) – Identification of body – Public heath concerns (e. g. infectious disease)

The inspection option • Formal external examination of the body by the pathologist at the Office of the Chief Medical Examiner • Used in cases where the cause of death is obvious, but circumstances may require “extraordinary” documentation

VT Medical Examiner System • So what happens? How does it work on a day to day basis? • A body is found…. . - or dies in an emergency room…… - or dies under circumstances that appear to fall under the Medical Examiner jurisdiction……

VT Medical Examiner System • Police and AME/RME are called and make a “proper preliminary investigation” – State’s Attorney is notified (technically in charge of body)

Suspicious case or scene: Criminal (Police) Investigation

Medical Investigation May or may not involve scene Options – Waive jurisdiction – Certify death (write death certificate) – Autopsy

Autopsy

Follow up investigation

Advantages • Medical Examiner model – Medically trained person examines body, reviews medical history and certifies death • Cause of death is a medical determination • Mechanism is a medical chain of events – Forensic pathology is more than just pathology – Appointed vs elected official (US) • Coroner model – Inquest by judicial officer (Australia)

And one final thought…. . “Show me the manner in which a nation cares for its dead, and I will measure with mathematical exactness their tender sympathies of its people their respect for the laws of the land, and their devotion to high ideals. ” - William E. Gladstone 1809 -1898