1. Forensic Pathology (aka Medicolegal Pathology)

2. What is Pathology?
Pathology: The scientific study of the nature of disease, its causes and consequences.
Subdisciplines are Clinical, Anatomical and Forensic Pathology.

3. Forensic Pathology
A branch of medicine that applies the principles and knowledge of the medical sciences to problems in the field of forensics (medicolegal).
Investigates and determines cause and manner of death.
Forensics: The scientific application of methods, techniques and procedures to the resolution of problems pertaining to the law.

4. History of Death Investigations
Death investigation techniques used in the U.S. today originated in England.
A Death Investigator was given the title of Coroner (crown)
Elected to protect the crown’s interests from corrupt sheriff’s.
A Coroner could arrest suspects including the sheriff.
This is still the case in Missouri.

5. The Inquest
The coroner was required to assemble a group of peers to judge a suspect’s guilt or innocence.
The group also considered the necessity of a postmortem (after death) examination or autopsy.
Antemortem (prior to death)

6. History of the Medical Examiner
New York city established the 1st city wide death investigations division.
In 1939, Maryland developed the 1st statewide death investigations division.
Today death investigations are performed differently from state to state and county to county.

7. Coroner/ME Jurisdiction
Sudden or Unexpected Death
Violent Deaths, e.g. homicide, suicides
Unattended Deaths
The person had not seen a physician for more than 20 days prior to death
Contagious Diseases, e.g., AIDS
Occupational Diseases, e.g. COPD

8. Coroner/ME System
California has Coroner/ME System separated by county.
We have more Coroner than ME systems.
Some States have either a CO or ME system or it is split by Region.

9. Coroner/ME System
Across the U.S., there are MORE Coroner Systems; these are generally represented under the setting of the Sheriff’s Office.
Some Coroner’s offices are also the local Funeral Homes.
U.S. (Federal) Government has their own system.

10. Coroner Usually an elected official
May be appointed by the Sheriff’s department
May be a physician
May be a medical examiner
It all depends on the county/state

11. Medical Examiner (also known as a Forensic Pathologist)
Must be a Pathologist who is a M.D. or D.O.
A doctor must have advanced training to become a ME or Forensic Pathologist.
To Become a Forensic Pathologist
Four years of undergraduate school
Four years of medical school
Internship and residency in pathology
Residency in Forensic pathology
Less than 1,000 board certified forensic pathologists in the U.S.

12. Medical Examiner’s Duties
Visits death scene on request
responds or has an investigator respond to all homicide related deaths
Reviews field investigative information
Performs autopsy (aka “posts”)
Autopsy means to “see for yourself”
Orders all ancillary tests & exams
Provides consultation to DA
Provides conclusions as to cause and manner of death

13. What types of death need investigating?
Violent Deaths (homicide, accidents, suicide)
Suspicious Deaths
Sudden and unexpected
Deaths without a physician in attendance
Death in custody
Deaths during or after a medical or surgical procedure

14. Death Investigator Works for Coroner/ME Office
Reports to the medical examiner or pathologist performing the autopsy.
Goes to the death scene and make an evaluation.
Gathers relevant medical history as well as talks to witnesses and relatives about the decedent’s last whereabouts.
Reports death to the next of kin.

15. Death Investigator
Usually an individual with law enforcement training or a:
Licensed registered nurse or
Trained mortician
Must attend the PC 832 course.
Must attend the coroner’s investigations academy after being hired by the coroner’s office.

16. Crime Scene Technician
Usually a member of local law enforcement.
Typically civilian personnel
The technician’s expertise includes:
Photographing and diagramming the death scene.
Collecting all potentially important evidence.
Recovering fingerprints
Recovering other prints such as shoes and tires

17. Criminalist The expert who works in the forensic lab.
Has a Master’s degree in criminalistics/forensic science
Most criminalists work with one particular type of evidence, such as:
Blood
Bullets
Ammunitions
Fibers
Hair
Impressions

18. Other Types of Forensic Investigators
Other specialists include:
Serologists
Questioned Document Examiner
Toxicologist
Anthropologist
Odontologist
Radiologist
Entomologist
Botanist
Meteorologist

19. Crime Scene Investigator
Forensic Pathologist
At scene of death controls body
Performs autopsies
Determines cause of death
Death Investigator
Works for the CO/ME office
Investigates cause of death
Crime Scene Investigator
Works for law enforcement
Collects evidence
Takes photographs
Criminalistic Specialist
Processes evidence in the laboratory

20. Forensic medicine is the application of various medical specialties to legal issues.
Pathology refers to the study of disease.
Forensic Pathologist is a medical doctor who studies injuries and disease to determine the cause and manner of death. (in suspicious deaths)
Medical Examiner is a forensic pathologist
who conducts autopsies to determine the cause, manner, and mode of death by examining the internal organs of the corpse.
Coroner is a public officer whose primary function is to investigate by inquest any death thought to be of other than natural causes.

21. Is a coroner the same as a medical examiner?
Each state has a law requiring that either a coroner or a medical examiner oversee the investigation of unexpected deaths.
Click here to watch video-clip
Medical Examiners vs Coroners
As you watch the video record the differences and similarities between medical examiners and coroners

22. Forensic Evidence
Evidence: Anything that can be used to determine whether a crime has been committed.
May exonerate the innocent
Corroborate or refute an alibi or statement of a witness
Identify a perpetrator or victim
Induce a confession

23. Forensic Evidence Direct Evidence: Establishes a fact
Eyewitness testimony
Confession
Circumstantial Evidence: Requires that a judge and/or jury make an indirect judgment or inference about what happened. No absolute proof; provides a general idea of what happened. Often much more reliable than Direct Evidence.
Fingerprints
Hair
Fibers

24. Forensic Evidence
Forensic evidence can’t find and convict the criminal unaided.
It provides an additional weapon in the detective’s armory.
It can offer clues to help the detectives track down the criminal and
It can help detectives prove a suspect was present at the crime scene or committed a particular act of violence.
The d’Autremont Brothers:
The forensic investigator was Edward Heinrich
Forensic Lab at Berkeley California.
A gang holds-up a mail train on the Union Pacific Railroad in southern Oregon.
The mail coach was blown up with dynamite and the entire crew murdered in cold blood.
The only thing found was a revolver, a battery-powered detonator a pair of shoe-covers made of sacking soaked in creosote to blot out the fugitives’ scent in case tracker dogs were used and a single pair of overalls.

25. Medicolegal Investigations
Duties of the medicolegal system
Determine cause, manner, mechanism and time of death
Four important medicolegal elements of death investigation.
Identify the deceased if unknown
Collect evidence from body
Document injuries or lack thereof
Deduce how injuries occurred
Provide expert testimony if case goes to trial

26. Definition of Death
In 1968 Black’s Law Dictionary defined Death as: the cessation of life; the ceasing to exist; defined by physicians as the total stoppage of the circulation of the blood, and cessation of vital functions consequent thereon, such as respiration, pulsation, etc.

27. What is Death? Cellular Death
The tissues and their constituent cells are dead.
No longer function or have metabolic activity, primarily aerobic respiration
From cardiorespiratory failure
Different tissues die at different rates

28. Definition of Death Clinical Death
The cessation of respiration and circulation functioning. Resuscitation may or may not be possible.
Anoxia and hypothermia
May live for more than 5 minutes after cessation of respiration and circulation.

29. What is Death? Somatic Death
Irreversible loss of personality, being unconscious, unable to be aware of or communicate with one’s environment, unable to appreciate any sensory stimuli or to initiate any voluntary movement.
Reflex nervous activity may persist and circulatory and respiratory functions continue either spontaneously or with artificial support so that the tissues and cells of the body, other than those already damaged in the central nervous system, are alive and functioning.

30. Definition of Death Brain Death An irreversible process.
Irreversible cessation of all brain functions, including brain stem.
PVS – Persistent Vegetative State = permanent damage to frontal lobe function and not brain stem.

31. Definition of Death Brain Death is determined by:
Coma and cerebral responsiveness
Apnea
Fixed and Dilated Pupils
Absence of Cephalic Reflexes (brainstem)
Absence of Electrical Impulses in the Cerebrum(no EEG pattern)
Two physicians required to pronounce brain death; one must be a neurologist in California.

32. Death Certificate Medicolegal requirement of the death certificate
Cause and
Manner of Death

33. Death Certificate
The death certificate has two major groupings for the cause of death:
Primary or immediate cause of death
Secondary cause of death

34. Primary Cause of Death
The Primary cause of death is subdivided into a three-link sequential chain
Primary cause of death:
Hypoxemic necrosis of brain (brain death) due to
Exsanguination due to
Gunshot wound (GSW) of abdomen

35. Secondary Cause of Death
Includes conditions which are not related to the primary cause of death but are substantially contributory to the individual’s demise
Emphysema of the lungs
Arteriosclerotic cardiovascular disease

36. Cause of Death The reason someone dies is the cause of death
Proximate cause of death refers to an underlying cause of death as opposed to the final cause.
The “original” underlying medical condition which initiates a lethal chain of events culminating in death.
i.e.. a shotgun blast to the head, stab wound to the chest or coronary atherosclerosis.
Immediate cause of death
What kills a person now, but was originally precipitated by something else (proximate)

37. Mechanism or Mode of Death
An abnormal physiological state that pertained at the time of death
i.e. coma, congestive heart failure, cardiac arrest, pulmonary edema, septicemia and hemorrhage
Mechanism of death describe the specific change in the body that brought about the cessation of life.
**usually only “Cause” and “Mechanism” are listed on the dead certificate**

38. Manner of Death
The circumstances surrounding a death or how the cause of death came about.
Circumstantial events or manner of death may be:
Natural due to disease or
Unnatural due to: Accident, Suicide, Homicide, Questionable/Undetermined.
NASH/Q

39. Certification of Death
Five Classifications of Death (NASH/Q)
Referred to Manner of Death
Natural: pathology; death caused by disease.
Accident: not intentional or by a criminal act.
Suicide: death by one’s own hand.
Homicide: death by another.
Questionable: cause and/or motive is not known; generally when other classifications are not used. Also “Undetermined” death is used. “Equivocal” has also been used as well.

40. Examples: Manner of death: - homicide Cause of death: - smothering Mechanism of death: - asphyxia Cause of death: - stabbing Mechanism of death: - loss of blood

41. Manner of death: - homicide Cause of death: - gunshot
Man shot during robbery. Man stabilizes. Develops pneumonia. Followed by kidney failure, liver failure, heart failure, death. Had prior lung and heart disease, and probably would have survived if not for these diseases.
Manner of death: - homicide
Cause of death: - gunshot
Mechanism of death: - heart failure

42. REVIEW CAUSES AND MECHANISMS OF DEATH
Examples of causes of death:
heart attack, gunshot wound, skull fracture, diseases or injuries, stroke, burning, drowning, strangulation, hanging, suffocation, massive trauma, bludgeoning
Examples of mechanisms of death:
Exsanguination (bleeding to death)
Sepsis (infection in blood stream)
Brain trauma (cerebral contusion)
Brain bleeding (intra-cerebral bleed)
Stop breathing (asphyxia)
Pulmonary arrest
Cardiac arrest

43. Whitney Houston death certificate: No cause of death listed
Click here ←
to read the news article.

44. Whitney Houston The manner, cause and mechanism of death of:
Jon Bennet Ramsey
Manner – homicide
Cause – strangulation
Mechanism – asphyxiation - respiratory arrest
Whitney Houston
Manner – accidental
Cause – drowning
Mechanism – Pulmonary arrest

45. Hugo Chavez Michael Jackson Manner – homicide
Cause – acute propofol intoxication
Mechanism – cardiac arrest
Hugo Chavez
Manner – natural
Cause – heart attack
Mechanism – Pulmonary arrest

46. You try
Write a short scenario that includes information about cause, manner and mechanism of death, without labeling them as such.
Exchange your scenario with other students and try to classify theirs.

47. Death Certificate Cause of death written on the death certificate:
Primary or Immediate
Secondary

48. Death Certificate Primary cause of death
Subdivided into a three-link sequential chain, eg.
Hypoxemic necrosis of brain (brain death)
Due to
Exsanguination
Gunshot wound

49. Death Certificate Secondary cause of death
Includes conditions which are not related to the primary cause of death but are substantially contributory to the individual’s demise
Emphysema of lungs,
Hypothermia
Arteriosclerotic cardiovascular disease

50. Autopsy Reports
Cause of death: Heart failure with cardiac arrhythmia due to a pulmonary emboli.
Contributing cause: Intestinal dismobility, on chronic pain management.
Manner of Death - Undetermined.

51. Tammy Wynette

52. Autopsy Report
A Psychological Autopsy may have to be done if manner of death is thought to be suicide.
An investigation of a decedent’s mental state prior to death.

54. Autopsy
Final photo of the King.

55. Autopsy
Autopsy Photo of Marilyn Monroe

56. Identification of the Deceased
Physical Description
Height
Weight
Color of eyes, hair and skin
Scars and Marks
Birthmarks, scars, etc.
Tattoos
Fingerprints

57. Identification of Deceased

58. Identification of Deceased

59. Identification of the Deceased
Photographs
The entire body should be photographed.
Radiological Features
X-rays should be taken of the body.

60. Identification of the Deceased
Age Determination
Age may be roughly estimated by the teeth
Joining of the bones (epiphysis)
Ossification center
Dental Features
The pattern of dental work may be determined by an Odontologist.
Eruption of Teeth

61. Identification of Deceased
Blood Factors
ABO groupings, Rh factors, DNA testing.
Medical Indications
Postmortem may reveal preexisting diseases.
Any Other Means Available
Clues may be found at the scene or in the personal effects.

62. Definition of Murder
P.C. 187: Unlawful killing of human being, or fetus, with malice aforethought.
1st Degree: by any of the destructive devices or explosive, use of ammo designed primarily to penetrate metal or armor, poison, lying in wait, torture, other willful, deliberate, premeditated killing, committed or attempted during a burglary, arson, rape, robbery, mayhem, carjacking, kidnapping, train wrecking or a drive-by shooting with intent to kill.

63. First-Degree Murder in California Law
California law, there are three ways to be convicted of first-degree murder:
By committing the murder using:
a destructive device or explosive, weapon of mass destruction, ammunition primarily designed to penetrate metal or armor or poison, or
by lying in wait or by inflicting torture,
By killing in a way that is willful, deliberate and premeditated, OR
By way of the felony-murder rule (that is committing a specifically enumerated felony that automatically turns any logically relate death into first-degree murder).

64. Second Degree Murder
Willful murder but is not deliberate and premeditated.
Second-degree murder is any murder that isn't defined as first-degree murder.
Shooting a gun into a crowded room and killing someone, even if that wasn't your intention
Vehicular Manslaughter; intoxicated driver.

65. Degrees of Murder
Manslaughter: Unlawful killing of a human being, without malice.
Voluntary: A sudden quarrel or in the heat of passion.
Involuntary: While committing an unlawful act, not a felony; or while committing a lawful act that might produce death, done in an unlawful manner; or without due caution and circumspection; provided that this subdivision shall not apply to acts committed in driving of a vehicle.
Vehicular: Drives in an unlawful way that produces death

66. Homicide Justifiable Homicide:
Public Officer: Homicide justifiable when committed by public officer, and those acting by their command in their aid and assistance.
Other Persons: (Including Peace Officers): When committed by a person in the following cases.
Resisting an attempted murder or felony.
In defense of habitation, property or person.
In lawful defense of persons such as wife, husband, child or parent.
In attempt to apprehend a person for committing a felony, lawfully suppressing a riot or lawfully keeping or preserving the peace.

67. Case 1
A 25 year old man was shot in the abdomen with a handgun. He was taken to the hospital where he underwent an emergency exploratory laparotomy. All life-threatening injuries were repaired. His postoperative course, however, was complicated by peritonitis which led to sepsis and eventually death two weeks after surgery. An autopsy revealed an extensive abdominal infection. The medical examiner ruled the cause of death as a gunshot wound to the abdomen and the manner of death as a homicide.

68. Case 1
During the trial, the pathologist was questioned about the cause of death. The pathologist reiterated his opinion that the decedent died from a gunshot wound. A fierce cross-examination followed. The defense attorney contended the man died as a result of an abdominal infection. Consequently, it was the physician, not his client, who was to blame for the death.

69. Case 1 Who should the jury believe?
Would the victim have died if the infection had been discovered sooner?
Should the physician be responsible for the man’s death?

70. Case Discussion Case 1
This man died as a result of a gunshot wound to the abdomen and the manner of death was homicide. It was a life-threatening injury which would have caused his death within hours if he had not been treated. A well-recognized risk of abdominal surgery is peritonitis. If he had been admitted with a non-lethal injury, and the physician made an error in judgment which caused his death, then the manner of death would have been an accident, not homicide.

71. Case Discussion Case 1
In this case, however, the pathologist correctly stated that the sequence of events was continuous from the time the man was shot until he died.
In the state of California the statute of limitations for this type of crime leading to the person’s death is one year

72. Case 2
A woman in her seventies was walking to a grocery store. An assailant pushed her onto the sidewalk as he grabbed her purse. She was apparently unharmed but obviously shaken by the experience. Within 10 to 15 minutes she developed shortness of breath, increased chest pain and was taken to a nearby emergency room. During her evaluation she developed an arrhythmia and died.

73. Case 2
An autopsy revealed severe atherosclerotic disease in all coronary arteries and numerous infarcts of the left ventricle. There were no signs of injury from the fall. The medical examiner ruled the cause and manner of her death as heart disease and homicide, respectively.

74. Case 2
During the trial, the defense attorney disagreed with the cause and manner of death. He stated this was not a homicide because the woman died of heart disease, and the fall to the sidewalk caused by his client was not a contributing factor. Was the pathologist correct? Should he have called the death a homicide? Did the man who took her purse actually cause her death?

75. Case Discussion Case 2
This case is more complex than Case 1. The manner, not the cause, of this woman’s death is in dispute. Since there was no significant trauma, the cause of death had to be the heart disease. He was more concerned with the sequence of events and how the pathologist believed the robbery was directly related to the death.

76. Case Discussion Case 2
There was only a minute interval from the time the woman was knocked to the ground to when she experienced signs and symptoms of a heart attack or angina. Since the time period was short, the pathologist believed that the woman was still under stress and correctly interpreted the manner of her death as a homicide. The longer the time frame, however, between the incident and heart attack, the more difficult it would be to make this interpretation.

77. Case Discussion Case 2
If, for example, the woman had gone home, had not been seen for a few hours, and then complained of chest pain, the same interpretation could not have been made. She would have been unwitnessed during that time and some other incident could have triggered a fatal arrhythmia. Consequently, in such a situation, her death could not be ruled a homicide.