1. Forensic Pathology: You Learn the Most From the Post Deaths associated with surgical or medical intervention February 21, 2015 Kent E. Harshbarger, M.D., J.D., M.B.A Montgomery County Coroner

3. Pretest Questions What medical therapy should be removed prior to reporting a death to the Coroner’s Office? A)Endotracheal tubes B)Central Lines C)Blood pressure cuff D)None * Why should medical facility or procedure deaths be investigated by the Coroner? A)Civil litigation B)Community protection/safety * C)Mandated by liability insurance company D)Ohio LAW requires facility deaths to be investigated by the Coroner

4. The Coroner Must Determine Cause and Manner of Death What Happened, Not Who Did It Up to Law Enforcement, Prosecutor, and the Judicial System to Decide Who Did It Cooperation with Your Law Enforcement Personnel is Key to Success (Avoid the Clinical Vacuum)

5. Coroner’s System In most communities, 50% of the deaths are reported to the Coroner/Police ¼ to ½ of these (12 to 25%) are autopsied –50% natural –30% accidental –11% suicide – 8% homicide

6. Investigation Summary - 2013 Deaths reported – 5179 Accepted for autopsy – 1416 (622) Accepted for external exam – 288 (BB-36) Accepted for records review - 82 2013 breakdown –Natural – 291 (28%) –Accident – 576 (56%) 220 overdoses/201 falls –Suicides – 84 (8%) –Homicides – 63 (6%) –Undetermined – 19 (2%)

7. Who Must Call The Coroner? Anyone Who Obtains Knowledge thereof Arising from His Duties, Shall Immediately Notify the Office of the Coroner Known Facts Concerning the Time, Place, Manner, and Circumstances of the Death Should Be Given Any Other Information Required

8. In What Types of Death is the Coroner Called? Deaths by Criminal or Violent Means (Homicides) Casualty (Accident) Suicide Suspicious or Unusual Manner Previous Apparent Good Health Child Under the Age of Two

9. In What Types of Death is the Coroner Called? Often jurisdictions or States have special rules –Alzheimer’s disease –Children –Sexual abuse/Elder abuse –Deaths in custody –Maternal or fetal death –Occupational deaths

10. In What Types of Death is the Coroner Called? The time period from the incident to the time of death is irrelevant. –If the decedent did not regain their health to a status equal to or better than that which was present at the time of the incident Notification does not equal jurisdiction –Coroner decides what cases need further investigation and/or autopsy

11. Death Investigation Other objectives/goals/needs –Reduction in crime –Impartial justice, civil lawsuits, and family rights protection –Home and work accident reduction –Vehicle accident reduction –Understand and reduce unexpected adult and infant deaths –Track public health, terrorism, infectious diseases

12. Delaware Madison Union Licking Fairfield Pickaway Fayette Clark Champaign Logan Hardin Allen Hancock Wyandot Marion Crawford Huron Richland Ashland Morro w Knox Coshocton Tuscarawas Carroll Harrison Belmont Guernsey Muskingum Monroe Noble Perry Morgan Washington Athens Hocking Meigs Gallia Vinton Jackson Lawrence Scioto Adams Pike Ross Highland Shelby Miami Montgomery Greene Darke Preble Mercer Auglaize Van Wert Paulding Defiance William s Putnam Henry Fulton Wood Lucas Ottawa Sandusky Seneca Erie Lorain Cuyahoga Medina Wayne Holmes Lake Geauga Ashtabula Trumbull Portage Summi t Stark Mahoning Columbiana Jefferson Clinton Brown Clermont Warren Butler Hamilton Franklin Counties Contracted Through The Montgomery County Coroner For Autopsies Montgomery County Coroner’s Office

13. Delaware Madison Union Licking Fairfield Pickaway Fayette Clark Champaign Logan Hardin Allen Hancock Wyandot Marion Crawford Huron Richland Ashland Morro w Knox Coshocton Tuscarawas Carroll Harrison Belmont Guernsey Muskingum Monroe Noble Perry Morgan Washington Athens Hocking Meigs Gallia Vinton Jackson Lawrence Scioto Adams Pike Ross Highland Shelby Miami Montgomery Greene Darke Preble Mercer Auglaize Van Wert Paulding Defiance William s Putnam Henry Fulton Wood Lucas Ottawa Sandusky Seneca Erie Lorain Cuyahoga Medina Wayne Holmes Lake Geauga Ashtabula Trumbull Portage Summi t Stark Mahoning Columbiana Jefferson Clinton Brown Clermont Warren Butler Hamilton Franklin Counties Contracted For Autopsies Counties Contracted for Toxicological Services Only *Licking County-Provide Toxicological Services and Back-Up Autopsies Montgomery County Coroner’s Office

14. Coroner/Medical Examiner Systems Coroners –Elected –In Ohio: MD, DO –Elected Lay Person (Illinois, Indiana) Funeral Director –Adult, Non-felon Coroner can arrest the Sherriff Coroner is back up Commissioner Medical Examiner –Appointed Professional, Generally Forensic Pathologist –State control vs. Local control –Medical Examiner/Coroner (Ohio, Kentucky, Illinois)

15. History of Death Investigation Coroner’s system traced to England Earliest record of a Coroner’s office is 925 Office formally described in 1194 –3 knights and 1 clerk in every county –“keepers of pleas of the crown” –Knight, B. The Medieval Coroner, 58 Medical Legal Journal 65- 80, (1990).

16. History of Death Investigation “Keepers of pleas of the crown” –Circuit court (General Eyre) every 7 years –Record crimes for later trial –If criminal cases forgotten the King would lose possible revenue “Crowners” –Knight, B. The Medieval Coroner, 58 Medical Legal Journal 65- 80, (1990).

17. History of Death Investigation Suicide Act of rebellion against the Gods –Denial of funeral rights King was entitled to decedents property

18. History of Death Investigation American Coroner’s System –Essentially the same system as in 1600 England –First recorded inquest in 1635, New England

19. History of Death Investigation First recorded autopsy in 1647 –Medical students First recorded medical legal autopsy 1665 –Mr. Francis Carpenter suspected of murdering his servant Samuell Yeoungman –Found depressed skull fracture and bruising –Achieves of Maryland

21. Hospital Death Investigations Hospital/Nursing Home Deaths  Quality of Care Patient/Community Safety – Coroner’s Jurisdiction Standard of Care – Civil Law Issue  Patient/Community Safety – Can policies and procedures be updated? Are certain procedures simply unsafe at a particular institution? Proper patient supervision and support

22. Hospital Death Investigations Investigation  Patient Safety  Quality of Care  Medications  Equipment Raising the index of suspicion  Altered scenes  Information gaps

23. Hospital Death Investigations NH death; 85 yo female  Pronounced dead: 5:20 AM  Death reported: 5:50 AM  Police and EMS respond and call Coroner Altered scene:  Decedent cleaned, evidence thrown away or moved, decedent moved History:  Suicidal ideations (family, staff, psychologist)  Recent death of husband, OD attempts x 3

24. Hospital Death Investigations Investigation/Scene:  Team Approach  Interoffice communication  Importance of relayed info versus medical record and gaps  Medical history Historical Information:  Injections  IV Lines/IV Line Flush  Transfusions  Procedures  Sequence of events  Unusual Symptoms/signs  Diagnostic testing  Time of death versus time of report  Persons involved

25. Hospital Death Investigations IV Line Flush Error  Elderly Male with central line  Heparin flush of central line to keep open  Approximately 1 hour later he was unresponsive with initial glucose of 13 two hours after line flush Blood insulin: 297 mcU/ml (0-23)  Testing on same tube as glucose level C-peptide was low- external source

26. Hospital Death Investigations IV Line Flush Errors  Where is the insulin stored?  What does the container look like?  How is the container labeled?  Who has access?  How many patients to RN?  RN Training and procedures?  Who on the floor is supposed to get insulin? Manner of death? Accident or intentional

27. Hospital Death Investigations Digoxin overdose:  Middle aged female  Digoxin ordered  RN first week of service Dosing error by decimal point, injected wrong dose by order of ten Death occurred within an hour of dose Diagnosis made clinically as symptomatic quickly

28. Hospital Death Investigations 91 year old white female, NH patient  NH patient x 5 years  Bedridden and severe osteoporosis  Unwitnessed fall from bed to floor Fracture distal right femur, no surgery Two weeks later, still pain, gastric ulcer and hematemesis, to hospital, LUQ bruise Family suspects patient dropped, QC issues

29. Hospital Death Investigations Postmortem Examination:  Fracture verified  Pulmonary Edema with consolidation  Atherosclerosis COD: Multiple Drug Toxicity (Morphine and Oxycodone)  Nursing notes document O.D. and adverse effects Manner: Accident

30. Hospital Death Investigations

32. Immediate deaths and delayed deaths Manner of death?  Determined based on circumstances

33. Hospital Death Investigations Epidemiology:  Database to track information: Facility Room number Attending/nurse Drugs used Frequency Patient sex DNR status  Keep asking questions!

34. Hospital Death Investigations Post procedure deaths  Most common reason for notification  Most related to family concerns about the standard of care (Civil)  Needs investigation to assure patient or community safety (Coroner’s jurisdiction)

35. Hospital Death Investigations Cardiac catheterizations

36. Hospital Death Investigations

45. Middle age male Many procedures, same surgeon, symptomatic Coded hours after ventral abdominal hernia repair

46. Hospital Death Investigations Patient/Community Safety – Coroner’s jurisdiction similar to roadway safety Quality of Care – Can be a safety issue Medications – Errors happen Equipment – Failures happen

47. Hospital Death Investigations