1. When a Natural Death Isn’t Natural Amanda James Chevas Yeoman Division of Aging Services

2. Joseph Shepter Died at age 76 in a Nursing Home The nursing home’s chief medical officer explained that the cause was heart failure brought on by clogged arteries No coroner review (attended death) Natural Death Right? http://www.propublica.org/article/gone-without-a-case-suspicious-elder-deaths-rarely-investigated

3. Joseph Shepter Tip from a nursing home staffer prompted state officials to re- examine the case Later determined that he had actually died of a combination of ailments related to poor care, including an infected ulcer, pneumonia, dehydration and sepsis Also concluded death was hastened by the inappropriate administration of powerful antipsychotic drugs Not a Natural Death http://www.propublica.org/article/gone-without-a-case-suspicious-elder-deaths-rarely-investigated

4. NOT ALL DEATHS ARE NATURAL “No elder death should be automatically assumed to have a natural manner based solely on age and past medical history.” K. Collins, 2015 AFP

5. Pre-existing conditions Fatal GSW – Head Manner: Homicide Pre-existing conditions Fatal Neglect (by other) Manner: Natural Manner

6. Cardiovascular Disease COPD Cancer Dementia Falls – susceptibility Medications – adverse reactions Over/Under Changes Attributed to Aging

7. Hip fractures Subdural hematomas Dementia Untreated decubitus ulcers Sepsis Malnourishment Improper medications Presence may obscure indicators of abuse, neglect & exploitation. May Hasten Death

8. Within a year, 30% of people 65 and older had a fall 50% of people 80 and older had a fall 38%-47% are fatal Sometimes people are pushed or tripped Falls

9. Time/Date of Fall Witnesses Location Landing Surface Use of throw rugs Strike intermediary object during fall (furniture) Causes given for both accidental and homicidal falls: Medications Frailty Totality of circumstances should be evaluated. Falls

10. Additional Issues Attended Deaths – Hospital, Hospice, Nursing Home Lack of Space for Medical Examiners and Coroners Complexity of Cases

11. “This [case] was a prolonged situation of being malnourished and starved.” Metro prosecutor about child neglect case and consideration of death penalty. Child Neglect

12. Older adults and adults with disabilities are neglected everyday. When are those deaths suspicious? Adult Neglect

13. Not enough time and resources to investigate every older adult death, so what can a medical examiner/coroner look for?

14. Prior/Frequent “911” calls to location History with Adult Protective Services (Decedent) History with Healthcare Facility Regulation (Facility) Repeated citations for serious violations Frequent name changes to Long-Term Care Facility Decubitus ulcers - untreated Evidence of Malnutrition, Dehydration, Starvation Weight below normal For disease process and age Table 1 Investigation of Elder Deaths Red Flags

15. Overall poor condition of body (hygiene, presence of urine/feces) Poor condition of residence/location (unsafe/unhealthy) Marks or Injuries to the body Unexplained or inconsistent with story provided Medications missing or inconsistent Efforts to prevent/obstruct investigation Incomplete or reluctant witness accounts Multiple unemployed adults in shared living arrangements Table 1 Investigation of Elder Deaths Red Flags

16. Considerations: Scene investigation Medicolegal death investigator’s report Photos Medical records (physical/psychiatric) Dietary/Rx Therapy recs Tox/Hist/Chem/etc. Financial history Social history Residence Independence Competency History: Medical * Social * Financial Autopsy

17. Addressing the Problem Medical Examiner/Coroner Training Standard Investigation Checklist Training of First Responders and Mandated Reporters

18. Fulton County Medical Examiner’s Office Data Elder Abuse, Neglect, and Exploitation Prevalence of the wrongfully assigned manner of death as natural Recognizing trends in health care facilities Setting a case definition based on a combination of ME, APS, and HFR data

19. Prospective Collection – Medical Examiner Sources Many different sources of Data Demographics Scene Information (Narrative and Pictures) Medications Medical conditions Evidence Narratives (Initial vs Follow-up) Autopsy Results Lab Results Police Reports

20. Outside Supplemental Sources HFR – Healthcare Facility Regulation Nursing Homes, Assisted Living Facilities, Personal Care Homes, Community Living Arrangements Licensing, Inspection, and Violation records APS – Adult Protective Services Any intake or referrals, cases opened, cases closed, substantiated vs unsubstantiated Family status Medical Hx

21. Outcomes Number of cases that were wrongfully recognized as a natural manner that can be attributed to abuse, neglect, and/or exploitation with auxiliary data points Trends of suspicious deaths related to specific nursing homes, personal care homes, and assisted living facilities Failure to report: Mandated Reporters Geolocated location of the incidents and place where declared deceased for mapping New data points and revised protocol so not to miss critical data to discover abuse, neglect, and exploitation

22. Fulton County Medical Examiner Project June 2014 initiated Review cases - decedents 65+ No Abuse – Possibly Not Abuse – Possibly Abuse – Abuse 1 st 100 cases reviewed: 27 + for possible ANE Next step: Compare data to protective and regulatory data, ER Data, & DV Registry To identify: trends, markers, etc. Current Project

23. Importance of Reporting Can’t have history or red flags without reporting Extremely important with attended deaths If you suspect abuse, neglect or exploitation, you need to report!!!

24. Reporting Many resources available to learn red flags and when to report. Mandated Reporter training available.

25. Adult Protective Services 1-866-552-4464 Press “3” www.aging.ga.gov “Report Elder Abuse” In the Community

26. Healthcare Facility Regulation 1-800-878-6442 www.dch.ga.gov Go to: “Healthcare Facility Regulation” Go to: “File A Complaint” In a LTC Facility

27. Many older adults die with their diseases and not of their diseases.

28. Forensic Special Investigation Unit Case Reviews Current Research Project with FCMEO Investigation of Elder Deaths, (2014) Academic Forensic Pathology Collins, K., Howe, K., King, P., Yeoman, C. Source Material