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

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

3. 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

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

5. Death Investigation: Types of Death Investigator Systems Coroner Medical Examiner

6. 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

7. –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: Medical Examiner

8. 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

9. 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

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

11. 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

12. 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

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

14. 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

15. VT Medical Examiner System ME Statute (T18§505- 509; 5205) –Medical Examiner Jurisdiction –Death Investigative Team –Authority to Order Autopsies

16. 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

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

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

19. The Death Investigative Team 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) Medical Examiner

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

21. The Death Investigative Team 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 Regional Medical Examiner

22. Problem in Rural Death Investigation: 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 In 1990’s Increasing Maldistribution of RME coverage

23. Increasing Maldistribution of RME coverage 1987 1997

24. The Death Investigative Team 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 Assistant Medical Examiner

25. The Death Investigative Team 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 Law Enforcement Officer

26. The Death Investigative Team 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 State’s Attorney

27. 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

28. - Medical - Legal Indications for Autopsy:

29. 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)

30. 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)

31. 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

32. 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……

33. 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)

34. Suspicious case or scene: Criminal (Police) Investigation

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

36. Autopsy

38. Follow up investigation

39. 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)

41. “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 And one final thought…..