1. 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

2. 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

4. 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

5. 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

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

7. 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)

8. 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)

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

10. 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

11. 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
Death Certificates are also public records, but copies must be obtained through vital records at the state or county level

12. 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

13. 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

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

15. 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)

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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).

23. 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

24. 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

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

26. Funding
Appropriations 63%
Receipts 23%
Grants 14%

27. 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

28. Statutes, Rules, and Guidelines
NC OCME Guidelines, Rules, and Statutes
Administrative Code
General Statutes
Guidelines for Medical Examiners

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

30. 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.