Deborah Radisch, MD, MPH January 24, 2014 North Carolina Medical Examiner System and the Office of the Chief Medical Examiner Deborah Radisch, MD, MPH January 24, 2014

Organization of Death Investigation Systems in the US Coroner – elected, usually lay official. County centered and funded. A few jurisdictions require that candidates be physicians and/or provide sufficient funding to obtain medical expertise. May hire pathologists to conduct exams but final decisions about/certification of cause and manner of death in individual cases may be made by the coroner. Medical Examiner – appointed, physician / medical knowledge. May have county or statewide jurisdiction. May be a forensic pathologist or not. County centered systems, county systems with central oversight, district systems. Justice of the peace, district attorney Systems can be mixed and vary from state to state and in some states from county to county THERE IS NO STANDARDIZED NATIONAL DEATH INVESTIGATION SYSTEM

North Carolina ME System Based on model legislation similar to that already in place in Maryland and Virginia. It was intended to utilize the pre-existing facilities and personnel that comprised the medical health care delivery system, local hospitals and physicians, to provide county medicolegal death investigation services Central oversight and professional support for the local MEs would be provided by the Office of the Chief Medical Examiner which would be a state function While it was originally intended that only MDs would serve as MEs the original statute allowed the coroner to serve as “acting” ME until a physician could be found and over the years PAs and RNs have also served as “acting” MEs It can be seen as a public/private cooperative enterprise with the current funding ~ 60% state dollars and 40% county

Major Program Areas Medicolegal Death Investigation State County Medical Examiners “de facto” Regional Centers /Pathologists Central Office Administrative Support Pathologists Toxicologists IT Child Fatality Prevention Team

ME Cases in NC ~ 11,000 cases investigated per year Of those, ~ 4500 are autopsied 2013 estimate: OCME 1175 autopsies OCME 779 externals

Deaths Requiring Medicolegal Investigation Unattended natural deaths No physician Physician but no life-threatening illness Break in medical care, but no specific time limit since last visit Visitors to NC, stranger from afar, non attendance by virtue of geography Sudden, unexpected, apparently natural deaths Deaths due to external causes = unnatural Manner: accident, suicide, homicide, undetermined Injury can be due to physical, chemical, thermal, electrical forces or radiation The injury may be the sole cause of death or contributory There is no time limit between the time of injury and death as long as the two can be linked causally, even if years have passed (proximate cause)

Deaths Requiring Medicolegal Investigation Other Cases Deaths possibly due to contagious disease – public health threat when a diagnosis must be established in order to determine whether others have been exposed and might need prophylactic treatment Bioterrorism Deaths in jail, prison or other correctional facility, under police custody or control Suspicious deaths Deaths in certain state institutions (Divisions of Mental Health, Developmental Disabilities and Substance Abuse Services)

County Medical Examiners Physicians Physician Extenders (PA, FNP) Nurses EMT-Paramedics Lay

ME Records and Payments ME Report of Investigation Must be sent to the OCME within 14 days Serves as an invoice ($100) ME Death Certificate - medical certification must be completed within 3 days and the DC filed with the health department within 5 days. The health dept. sends a copy to the OCME Autopsy Report To the OCME by 180 days $1250

ME Records ME Reports, ME Autopsy Reports, and results of toxicology tests become public records available to any requester after receipt and review at the OCME www.ocme.unc.edu Death Certificates are also public records, but copies must be obtained through vital records at the state or county level

OCME as Medical Examiner OCME serves as the primary medical examiner for Wake, Franklin, and Durham counties, regular back-up for several close-by counties, and potential back-up for any county or regional pathology center

Death Investigation Realities CONTRARY TO THE PUBLIC IMPRESSION OF HOW DEATH INVESTIGATIONS ARE CONDUCTED – the “CSI EFFECT” Crime scene processing is conducted by crime scene technicians Evidence is analyzed by crime lab technicians Crimes are investigated by law enforcement officers and they identify interrogate and arrest suspects The court system decides matters of guilt and innocence The role of the Medical Examiner in criminal matters is to provide sound, medically based evidence in regard to the cause (and manner) of death of the victim The role of the ME is to determine WHAT DID IT, NOT WHO

Case Flow Law Enforcement, first responders (EMS, Rescue, Fire Departments), medical personnel County Medical Examiners Regional Pathologists OCME

Regional Centers Brody School of Medicine-Greenville 4 Forensic Pathologists WFU School of Medicine-Winston-Salem 3 Forensic Pathologists Mecklenburg County-Charlotte Other Jacksonville*, Clinton, Hickory, Sylva, Lumberton (no ABP certified FPs)

Medical Examiner Autopsies in North Carolina Current centers Current pathologists Future regional offices ??

Medicolegal Autopsy Not every death that comes under medical examiner jurisdiction requires an autopsy An autopsy is “ordered” when it is deemed “advisable and in the public interest” as defined by guidelines promulgated by the OCME ME autopsies do not require the consent of the next of kin and an objection by the NOK is not a bar to the exam All ME autopsies are complete autopsies Medicolegal autopsies are performed by designated regional pathologists or by the OCME Pathology Branch A little over 40% of ME cases in NC are autopsied. Not all trauma deaths have an autopsy

Medicolegal Autopsy Purposes : Identification Collect evidence Document injuries and natural disease Collect samples for special testing Try to narrow down where and when injured/died Opinion as to cause and manner of death

Central Office Functions Administrative Case Management Assemble case files for all ME cases in NC except Mecklenburg county Public interface Subpoena management Case coding and data entry Budget Purchasing IT

Central Office Functions Pathology Support Transcription Histology: includes Mecklenburg, for ~2000 cases per year, average of 6 glass slides per case Morgue technician staff Radiology Photography Investigation Ancillary: Anthropology Odontology Neuropathology Laboratory

Central Office Functions Six forensic pathologists and one fellow (training) Autopsies Review all ME cases in NC = QA, before public record Consultation Testify Teaching Mass fatality planning and management

Central Office Functions Court Testimony In 2011, OCME pathologists testified in court 39 times, a fraction of the subpoenas they received and for which they were on telephone stand-by. The total time, travel and court (testimony and waiting), was 190 hours. Toxicologists are being subpoenaed to appear more frequently (Melendez-Diaz).

Central Office Functions Teaching Forensic Pathology Fellowship Program Director Pathology Residents (1 month required) UNC, Duke Medical Students Second year (all) and elective rotation Pathology Assistant Students (Duke) Miscellaneous presentations

Central Office Functions Toxicology All ME testing in NC More than 10,000 cases per year, with more than twice that many analyses Screen, then confirm and quantitate

Central Office Functions Child Fatality Prevention Team 2 (-1) Investigator/Trainer Researcher

Funding Appropriations 63% Receipts 23% Grants 14%

Major Stakeholders Families Law Enforcement District attorneys, defense attorneys, plaintiff’s attorneys Vital Records Funeral Directors Legislators EMS Medical practitioners, including VA Public Health professionals Transporters Media

Statutes, Rules, and Guidelines NC OCME Guidelines, Rules, and Statutes http://www.ocme.unc.edu/rules/index.shtml Administrative Code General Statutes Guidelines for Medical Examiners

Priorities National accreditation Medical Examiner training Improved communication Appropriate death certification Regionalization

Mission Statement The North Carolina Office of the Chief Medical Examiner will ensure consistent and competent medicolegal death investigation by utilizing training, consultation, quality assurance, and the appropriate use of resources.