GMS6360 MOD 4 MEDICAL LEGAL DEATH INVESTIGATION
4.1 Case investigation
· A death investigation by a medical examiner or coroner office does not end with the interpretation of the autopsy results. A full investigation using the resources of many partner organizations is necessary to determine the exact cause and manner of death.
· Approximately 20% of deaths within the United States are subject to a full investigation by a medical examiner’s or coroner’s office.
· Although each case is individualized, certain basic principles must be followed to avoid wrongful convictions and liabilities for all investigating organizations. Scenes must be carefully and systematically photo documented; police narratives must be reviewed and medical records must be analyzed and interpreted in order for the proper cause and manner of death to be concluded.
4.1.1 Death scene investigation
· The investigation of a scene starts with photography of the undisturbed scene. The evidence and surrounding environment must be photographed in a regimented fashion so that the subject matter is presented in context with its surroundings. Each subject should ideally be photographed first by a long-distance picture or ‘orientation shot”.
· This is necessary for establishing a perspective on the subject matter and its relationship with the environment surrounding it. The next picture should be a midrange shot, this will bring into focus the objects near the subject, demonstrate spatial relationships, range of fire gunshot determination and accident reconstruction. The last picture should be a close up of the subject to bring out the most detail possible. Detailed analysis of blood splatter is best seen on these close-up photos. This is especially significant as the most important for analysis’ sake.
Figure 4.1.1: A wall containing blood spatter that would best be documented for death investigation context using midrange photography.
4.1.2 Patient history
· Patient history is of paramount importance when investigating death scenes most especially those that are non-violent and occur within the decedent’s home. A long history of cardiac disease, cancer, strokes and pulmonary disease can support a natural manner of death when the events leading up to the demise of the individual is investigated. A decedent discovered in a clandestine location with apparent needle punctures would best be served by an inquisition into their drug or medication history. This case can be an accidental drug overdose or perhaps a case of ketoacidosis in an insulin dependent diabetic who was not using the correct amount of insulin.
· The medical records and drug history can lead to this case in the proper direction.
Figure 4.1.2: A needle and syringe of an unknown substance discovered at a death investigation scene. The discovery of such an item necessitates a thorough toxicology screening and drug history of the decedent.
4.2 Autopsy Findings
· Important in every death investigation is a complete understanding of the autopsy report.
· Each finding can yield supporting evidence of a witness statement or refute the statements of a suspect.
· It is important that each finding be interpreted in the context of the circumstances surrounding the time of death so that the correct person responsible for the death can be brought to justice.
4.2.1 The Autopsy Report
· The autopsy report can provide a list of injuries observed on the decedent as well as the medical problems they may be suffering from.
· From these findings it may be possible to accurately determine the cause and manner of death. The report does have its limitations.
· In cases of multiple gunshot wounds, the report will list the number of wounds, their location, size and the damage done to the internal organs.
· It cannot determine the order in which the bullets were fired or which bullets struck the body first.
· In a case where a decedent has competing causes of death, for instance hypertensive cardiovascular disease, insulin dependent diabetes and chronic obstructive pulmonary disease it may be difficult to determine which one of the three conditions was the ultimate cause of death. In instances like this the pathologist may list one of the three conditions as the cause of death and list the remaining two as “contributors” in the cause of death “part 2” section.
· Other examples may include a decedent with a negative autopsy, a negative toxicology report, no medical history and where the circumstances surrounding their death are unknown. The cause and manner of these deaths may be classified as undetermined.
Figure 4.2.1: A decedent with a gunshot wound to the gluteal region. The number of wounds associated with a single gunshot wound are documented numerically.
4.2.2 Further Testing and Studies
· Ancillary testing of blood and body tissues is extremely important in determining the cause and manner of death.
· Consider a scene where a previously healthy decedent is discovered with no injuries and negative autopsy findings.
· At this point the forensic pathologist will have to consider sending samples of blood and tissue samples for toxicology and histology respectively.
· After receiving the toxicology report the results are negative for drugs of abuse, medications and ethanol.
· The histology slide of the lung demonstrates an infiltration of acute and chronic inflammatory cells in the alveolar air spaces and interstitium.
· The forensic pathologist now has the cause of death as bronchopneumonia and the manner of death as natural.
· This would have been nearly impossible to confirm without the additional testing of the lung tissue.
· In cases of an infant death within a residence, a scene reenactment with the caretaker and a doll can help to elucidate the circumstances surrounding the death. Additional histology specimens are also taken in infant deaths to identify possible birth anomalies or defects.
Figure 4.2.2: A histology slide of lung tissue demonstrating the alveolar spaces filled with neutrophils, consistent with a diagnosis of pneumonia.
4.3 Correlation vs. Cognition
· The process of correlation is a technique that investigators use to improve the accuracy of determining the cause and manner of death. In summary, the evidence recovered at the scene, the law enforcement narrative, toxicology report, ballistic report and the autopsy results must all support a single cause and manner of death.
· Cognition is the pathologist’s use of years of training, reading and experiences to interpret a complicated and often overlapping set of results in a single case. For instance, if a decedent is observed to have multiple injuries a pathologist using cognitive abilities can segregate them into cardiopulmonary resuscitation related injuries and other injuries caused by malicious intent.
· Interpretation of toxicology results is one of the best examples of cognition a pathologist utilizes. Over the course of time a person can develop a tolerance to certain medications. High concentrations of a particular medication in a tolerant person may be the correct therapeutic level for their symptoms. The same concentration in a person naive to the medication can yield fatal results.
4.3.1 Correlation
· Correlation is the observation of the autopsy findings and using them to make an association with the circumstances surrounding the cause of death. Consider a case where a decedent is brought to the medical examiner’s office after being found outside of a night club. He has bruises on his face and torso. Both of his wrists have contusions and linear abrasions encircling them consistent with that of a binding apparatus.
· The police narrative states the decedent was inside of the night club where he was involved in a verbal altercation, it was also observed he appeared intoxicated.
· Employees of the night club were last seen escorting the gentleman off the premises. It is important to correlate the injuries to the events surrounding his death. Additional interviews with the night club employees revealed the decedent was handcuffed and punched numerous times by the “bouncer”. After the additional inquiries were made the injuries on the body now correlates with the circumstances surrounding his death. The bouncer was eventually charged with homicide.
Figure 4.3.1: A wrist demonstrating injuries consistent with a binding apparatus.
4.3.2 Cognition
· Cognition is a combination of knowledge, perception and judgment a pathologist uses to help develop their logic in forensic problem solving.
· It is a process whereby each case is taken separate and apart from the ones before it. Every piece of evidence is critically analyzed and compared to known scientific literature.
· Its goal is to prevent a forensic pathologist from falling into the trap of rote thinking, overreliance on non-contributory data for the purposes of avoiding errors of judgment.
· Cognition teaches how to make proper sense out of incomplete data, a common occurrence in forensic death investigation.
4.4 Professional Liability
· Professional liability covers negligence related to professional services or advice. For example, a pathologist could face a lawsuit for providing an erroneous report that results in the wrongful conviction of an innocent person.
· The purpose of cognition and correlation is to reduce the incidence of errors on the part of the pathologist by providing a framework for logical decision making.
· Liability on the part of the pathologist falls into two categories, errors during the autopsy investigation and errors of testimony.
· Errors of testimony generally occur when a physician testifies on a topic that is beyond their experience and training. In order to reduce the professional liability of the pathologist it is recommended they advise a specialist to testify in areas outside of their expertise, rather than speaking to areas about which they are not extremely familiar.
· If a pathologist uses an outside report or expert to form their opinion, examples include anthropology or toxicology, the pathologist is liable for errors in that report. It is an obligation of that pathologist to determine if the findings in the outside report are sound and based on good science and follow appropriate techniques. For example, pathologists would always require accredited toxicology labs to do medical/legal testing as they would be liable for issues in that testing during testimony.
· Other ways a physician can limit professional liability is to engender a professional lifestyle of continual education improvement, properly document and investigate the circumstances leading up to death, exercise proper cognitive judgment in the correlation of circumstances with autopsy and be aware of legal pitfalls and how to avoid them.
