1. Manner: Natural Marnie Wood MD FRCPC March 10, 2015

2. 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

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

4. 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%

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. 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)

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